HomeMy WebLinkAbout2772 ROOSEVELT ST; ; CB930847; Permit~ .. ' ,.
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CITY OF CARLSBAD
2075 Las Palmas Dr., Carlsbad, CA 92009 (619) 438-1161
PERMIT APPLICATION
City of ta!lilsbad Building Departinent
2075 Las Palms Dr., Carlsbad, CA 92009 (619) 438-1161
I. PilltMI I IYPE
A -LI Commercial
B -0 Industrial
C -□ Residential
D New Building D Tenant Improvement
□ New Building D Tenant Improvement
D Apartment D Condo D Single Family Dwelling □Addition/Alteration
D Duplex D Demolition D Relocation D Mobile Home □ Electrical D Plumbing
□ Mechanical D Pool D Spa D Retaining Wall D Solar □ Other ____ _
PLAN CHECK NO.
2. PROJECf lNl'ORMATION FOR OFFICE USE ONLY
Address d) 17 d-\l~e\+ 5{Du1lding or Su11e No.
Nearest Cross Street
LEGAL DESCRIP'l loN Lot No. Su!xhv1S1on Name/Number Unit No. Phase No.
CHECK Bf'.UM IF s0BMI I I f'.D:
□ 2 Energy Cales □ 2 Structural Cales □ 2 Soils Report □ I Addressed Envelope
ASSESSOR'S PARCEL EXISTING USE PROPOSED USE
DESCRIPTION OF WORK
SQ. FT. I 7 ~ ~ # OF STORJES
3. WN IACI PERSON (1rierenl lrom apphcan[)
NAME ADDRESS
CI1Y STATE ZIP CODE DAY TELEPHONE
l.\j . ~c.tt~ 51-.1~~ ~ TA.L..
CI1Y }...e►; ~ ~\~'7 STATE C,/4.
s. ~=~:~:1~y ~c.,.~,ly \~v4+
ZIP CODE9::ee "7S'.
ADDRESS b ;2. '3 5
ZIP CODE ~ 13 ;t. S
DAY TELEPHONE _2t ;> -'f3 '3 -30'17'
CITY ~c.,,~ STATE (_14..._ DAY TELEPHONE </ ( 't$ -7 ::r I::, -0 00 '7
6. OON IMCIOR
NAME ADDRESS
STATE ZIP CO_g!L. DAY TELEPHONE
STATE LIC. # C-(ca ~~E CLASS CI1Y BUSINESS LIC. #
DESIGNER NAME ADDRESS
CITY STATE ZIP CODE DAY TELEPHONE STATE LIC. #
1. WOilRElts' OOMP£NSAl1ON
Workers' Compensation beclarauon: I hereby al it rm that I have a cerultcate of consent to sell-insure issued by the Director ol Industnal
Relations, or a certificate of Workers' Compensation Insurance by an admitted insurer, or an exact copy or duplicate thereof C.!:.._rtif@""J /,
by the Director of the insurer thereof filed with the Building Inspection Department (Section 3800, Lab. C). r)"J' / ~
INSURANCE COMPANY ":,{t,...\ ~ POLICY NO./~ 5'0..3 EXPIRATION DATE / O ~ I .-<:f 3
ru 1care o xempuon: ceru L at in t e pe ormance o L e wor or w 1c t 1s permit 1s 1ssu , s a not emp oy any person in any manner
so as to become subject to the Workers' Compensation Laws of California.
SIGNATURE~ DATE
· OECI.AltAlidN
Owner-Builder beclarauon: I hereby a!hrm that I am exempt from the Contracto?s License Law for the following reason:
D I, as owner of the property or my employees with wages as their sole compensation, will do the work and the structure is not intended or
offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds
or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended
or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden
of proving that he did not build or improve for the purpose of sale.).
D I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's Llcense Law does not apply to an owner of property who builds or improves thereon, and contracts for such projects
with contractor(s) licensed pursuant to the Contractor's Llcense Law).
D I am exempt under Section _______ Business and Professions Code for this reason:
(Sec. 7031.5 Business and Professions Code: Any City or County which requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement chat he is licensed pursuant to the
provisions of the Contractor's Llcense Law (Chapter 9, commencing with Section 7000 of Division 3 of the Business and Professions Code)
or that he is exempt therefrom, and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than live hundred dollars ($500]).
SIGNATIJRE DATE
coMPLEIE THIS SEGIION FOR NON-RESIDENTIAL BUILDING PERMITS ONLY:
Is the applicant or future building occupant required to submit a business plan, acutely hazardous materials registration form or risk management and
prevention program under Sections 25505, 25533 or 25534 of the Presley-Tanner Hazardous Substance Account Act?
□ YES ONO
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district?
□ YES □ NO
Is the facility to be constructed within 1,000 feet of the outer boundary of a school site?
□ YES D NO
lF ANY OF THE ANSWERS ARE YES, A FINAL CERTIFICATE OF oa;uPANCY MAY NOT BE ISSUED AFTER JULY 1, 1989 UNLF.sS TIIE APPUCANT
HAS MET OR IS MEETING TIIE REQUIREMENTS OP lllE OFFICE OF EMERGENCY SERVI~ AND THE AIR POILU110N CX>NTROL DISTIUCT.
9. OONSrn0CIION ttNblNG AGENCY
I hereby affirm that there 1s a construct,on lending agency tor the performance of the work for which this permit 1s issued (Sec 3097(1) C1vtl Code).
LENDER'S NAME LENDER'S ADDRESS
JO. AllPUCAN"t cER'l1FicA'tidN
I cerufy that I have read the applicauon and state that the atx>ve mlormauon 1s correct. I agree to comply with all City ordinances and State laws
relating to building construction. I hereby authorize representatives of the City of Carlsbad to enter upon the above mentioned property for inspection
purposes. I AI.50 AGREE 10 SAVE INDEMNil'Y AND KEEP 1-IAR.MLF.SS THE QTY OF CARISBAD AGAINST AU. UABlIII1F.S, JUDGMENTS, CX>SfS
AND EXPENSES WIUOI MAY IN ANY WAY Aa:RUE AGAINST SAID QTY IN CX>NSEQUENCE OP nm GRANTING OF nos PERMIT.
OSHA: An OSHA permit is required for excavations over 5'0" deep and demolition or construction of structures over 3 stories in height.
Expiration. Every permit issued by the Building Oflicial under the provisions of this Code shall expire by limitation a nd become null and void if the
building or work authorized by such permit is not commenced within 365 days from the date of such permit or if the building or work authorized by
such permit is suspended or abandoned at any time after the work is commenced for a period of 180 days (Section 303(d) Uniform Building Code).
APPLICANTS SIGNATURE ___ ..._.,_"l DATE: 5('-;l..z:> -9 ,3
'
TIME ARRIVE: ____ TIME LEAVE: ____ _
CD :LVL DESCRIPTION ACT COMMENTS
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