HomeMy WebLinkAbout2656 LEVANTE ST; ; CBR2020-0234; PermitBuilding Permit Finaled
Residential Permit
Print Date: 07/01/2021
Job Address:
Permit Type:
Parcel#:
Valuation:
Occupancy Group:
#of Dwelling Units:
Bedrooms:
Bathrooms:
Occupant Load:
Code Edition:
Sprinkled:
Project Title:
2656 LEVANTE ST,
BLDG-Residential
2162202500
$29,338.40
CARLSBAD, CA 92009-8118
Work Class:
Track#:
Lot#:
Project#:
Plan#:
Construction Type:
Orig. Plan Check#:
Plan Check#:
Description: ZIMMERMAN: 560 SF POOL
Property Owner:
Pool
ZIMMERMAN JOSEPH P & ZIMMERMAN
SHIRLEY R
FEE
BUILDING PERMIT FEE ($2000+)
BUILDING PLAN CHECK FEE (BLDG)
2656 LEVANTE ST
CARLSBAD, CA 92009
ELECTRICAL BLDG RESIDENTIAL NEW/ADDITION/REMODEL
PLUMBING BLDG RESIDENTIAL NEW/ADDITION/REMODEL
SB1473 GREEN BUILDING STATE STANDARDS FEE
STRONG MOTION-RESIDENTIAL
SWPPP INSPECTION FEE TIER 1 -Medium BLDG
SWPPP PLAN REVIEW FEE TIER 1-MEDIUM
Total Fees: $882.41 Total Payments To Date: $882.41
('city of
Carlsbad
Permit No: CBR2020-0234
Status:
Applied:
Issued:
Fina led Close Out:
Inspector:
Final Inspection:
Contractor:
PRP AQUATICS INC
Closed -Finaled
01/30/2020
02/25/2020
TAlva
07/01/2021
5431 AVENI DA ENCINAS, # STE B
CARLSBAD, CA 92008-4411
(916) 743-2290
Balance Due:
AMOUNT
$278.00
$194.60
$41.00
$62.00
$2.00
$3.81
$246.00
$55.00
$0.00
Please take NOTICE that approval of your project includes the "Imposition" of fees, dedications, reservations, or other exactions hereafter
collectively referred to as "fees/exaction." You have 90 days from the date this permit was issued to protest imposition of these
fees/exactions. If you protest them, you must follow the protest procedures set forth in Government Code Section 66020(a), and file the
protest and any other required information with the City Manager for processing in accordance with Carlsbad Municipal Code Section
3.32.030. Failure to timely follow that procedure will bar any subsequent legal action to attack, review, set aside, void, or annul their
imposition.
You are hereby FURTHER NOTIFIED that your right to protest the specified fees/exactions DOES NOT APPLY to water and sewer connection
fees and capacity changes, nor planning, zoning, grading or other similar application processing or service fees in connection with this
project. NOR DOES IT APPLY to any fees/exactions of which you have previously been given a NOTICE similar to this, or as to which the
statute of limitation has previously otherwise expired.
Building Division Page 1 of 1
1635 Faraday Avenue, Carlsbad CA 92008-7314 I 760-602-2700 I 760-602-8560 f I www.carlsbadca.gov
Plan Check
Est. Value {cicyof
Carlsbad
RESIDENTIAL
BUILDING PERMIT
APPLICATION
B-1
PC Deposit ---------
Date 1 -1D<10
Job Address---=;).c.;.;6::...'5::...b,::.._.::.l,e-=....:..vc:.._,,.:....+e_...=S_t;__ ____ .Suite: ___ APN: 'd-\ b-°d?D -?--r -m
CT/Project#: _________________ Lot#: ___ _
Fire Sprinklers: yes/ no Air Conditioning: yes/ no Electrical Panel Upgrade: yes/ no
BRIEF DESCRIPTION OF WORK: _,f....:o::..::o'-'\'--.::...5'"_,b"---=-()-~-~~-r'--)r'------------------
□ Addition/New: ______ Living SF, ____ Deck SF, ____ Patio SF, ____ Garage SF
Is this to create an Accessory Dwelling Unit? Yes/ No New Fireplace? Yes/ No, if yes how many? __
D Remodel: _____ SF of affected area Is the area a conversion or change of use ? Yes/ No
Pool/Spa: 5bo SF Additional Gas or Electrical Features? .:w~~!::c .. S=!!-::>:::__ ______ _
□ Solar: ___ KW, ___ Modules, Mounted: Roof/ Ground, Tilt: Yes/ No, RMA: Yes/ No, Battery: Yes/ No
Panel Upgrade: Yes/ No
D Reroof: ___________________________________ _
D Plumbing/Mechanical/Electrical Only:
D Other:-----------------------------------
APPLICANT (PRIMARY CONTACT) PROPERTY OWNER
Name: U✓-1',e,. }~j Name: Joca....:;2~,-..,<z:,
Address: s'7e{3 /:1,.p • .1 Iv 'l ~.t: P,,{ ,-%,Z.O), Address: ?-l, S 6 lev""-'1C-S-t-
City: 5S> State: C Zip: q21oe City: ¼\.1.\, .. ....{ State: CA Zip:'3~5
Phone: ,t. iq J "13 5'5ob Phone: _ __.l-f_..:..: 1/2.=----...!'--"2k=-----""-b--'l..f"'-IJ7--'---------
Email: CA✓/',21•AJ@'h:,t..,,,.,1 I .,:::<Jr-\. Email: . ---------------------
DESIGN PROFESSIONAL
Name: _________________ _
Address: ________________ _
City: _______ State: ___ ,Zip: ___ _
Phone: _________________ _
Email: _________________ _
Architect State License: ___________ _
CONTRACTOR BUSINES~ 1
Name: ~<'e.M..e/ t'Q)\ &. ~ Sf'¾
Address: S:'-(3\ /..J t.v,,~e, &c •-"c:J
City: (}vi~ ~,I. StateCA Zip: q2.oo'6
Phone: '7t?O-Lf)b-DJ20f2
Email:---~~--------~~~---~
State License: 9q'2.. l) '1 Bus. License:Bl,J\\().. IJ\,\6~q
(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 that he/she is licensed pursuant to the provisions of the Contractor's License Law
{Chapter 9, commending with Section 7000 of Division 3 of the Business and Professions Code} or that he/she is exelTlpt therefrom, and the basis for the alleged
exemption. Any violation of Section 7031.S by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars {$500}).
1635 Faraday Ave Carlsbad, CA 92008 Ph: 760-602-2719 Fax: 760-602-8558 Email: Building@carlsbadca.gov
8-1 Page 1 of 2 Rev. 06/18
( OPTION A): WORKERS'COMPENSATION DECLARATION:
I hearby affirm under penalty of perjury one of the following dee/orations:
□ I have and will maintain a certificate of consent to self-insure for workers' compensation provided by Section 3700 of the Labor Code, for the performance of the
work which this permit is issued.
'-fu have and will maintain worker's compensation, as required by Section 3700 of the Labor Code, for e performance of the war for which this permit is issued.
l,;y workers' compensation insurance carrier and policy number are: lnsuranc~m~apName: \ C,
Policy No, C£,b D ('.?':lb"") Expiration Date: 0 40 I ('2,,o
□ Certificate of Exemption: I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to be come
subject to the workers' compensation Laws of California. WARNING: Failure to secure workers compensation coverage is unlawful, and shall subject an employer to
criminal penalties and civil fines up to $100,000.00, in addition the to the cost of compensation, damages as provided for In Section 3706 of the Labor Code,
interest and attorney's fees.
CONTRACTOR SIGNATURE: _0-----------:..__ ____________ ~GENT DATE:~ d~/ "7g)
( OPTION B ): OWNER-BUILDER DECLARATION:
I hereby affirm that I am exempt from Contractor's License Law for the following reason:
□ 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).
□ 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 License 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 License Law).
□ I am exempt under Section ________ Business and Professions Code for this reason:
1. I personally plan to provide the major labor and materials for construction of the proposed property improvement. □ Yes □ No
2. I (have/ have not) signed an application for a building permit for the proposed work.
3. I have contracted with the following person (firm) to provide the proposed construction (include name address/ phone/ contractors' license number):
4. I plan to provide portions of the work, but I have hired the following person to coordinate, supervise and provide the major work (include name/ address/ phone/
contractors' license number):
5. I will provide some of the work, but I have contracted (hired) the following persons to provide the work indicated (include name/ address/ phone/ type of work):
OWNER SIGNATURE: ___________________ □AGENT DATE: _____ _
CONSTRUCTION LENDING AGENCY, IF ANY:
I hereby affirm that there is a construction lending agency for the performance of the work this permit is issued (Sec. 3097 (i) Civil Code).
Lender's Name: ______________________ Lender's Address: _____________________ _
ONLY COMPLETE THE FOLLOWING SECTION 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, 2SS33 or 25534 of the Presley-Tanner Hazardous Substance Account Act? □ Yes □ No
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 □ No
IF ANY OF THE ANSWERS ARE YES, A FINAL CERTIFICATE OF OCCUPANCY MAY NOT BE ISSUED UNLESS THE APPLICANT HAS MET OR IS MEETING THE
REQUIREMENTS OF THE OFFICE OF EMERGENCY SERVICES AND THE AIR POLLUTION CONTROL DISTRICT.
APPLICANT CERTIFICATION:
I certify that I have read the application and state that the above information is correct and that the information on the plans is accurate. I agree to comply with all
City ordinances and State laws relating to building construction.
I hereby authorize representative of the City of Carlsbad to enter upon the above mentioned property for inspection purposes. I ALSO AGREE TO SAVE, INDEMNIFY AND KEEP
HARMLESS THE CllY OF CARLSBAD AGAINST ALL LIABILITIES, JUDGMENTS, COSTS AND EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID Cl1Y IN CONSEQUENCE OF
THE GRANTING OF THIS PERMIT.OSHA: An OSHA permit is required for excavations over5'0' deep and demolition or construction of structures over 3 stories in height.
EXPIRATION: Every permit issued by the Building Official under the provisions of this Code shall expire by limitation and become null and void if the building or work authorized
by such permit is not commenced within 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 ape · tt o 180 days (Section 106.4.4 Uniform Building Code).
APPLICANT SIGNATURE:-:::::_ _________________ DATE: __._[4/_14-1-('-JD=----
1635 Faraday Ave Carlsbad, CA 92008
B-1
Ph: 760-602-2719 Fax: 760-602-8558
Page 2 of 2
Email: Building@carlsbadca.gov
Rev. 06/18
PERMIT INSPECTION HISTORY for (CBR2020-0234)
Permit Type: BLDG-Residential
Work Class: Pool
Status: Closed -Finaled
Application Date: 01/30/2020 Owner: COOWNER ZIMMERMAN JOSEPH P &
ZIMMERMAN SHIRLEY R
Issue Date: 02/25/2020 Subdivision: LA COSTA SOUTH UNIT #4
Expiration Date: 11/10/2021
IVR Number: 24528
Address: 2656 LEVANTE ST
CARLSBAD, CA 92009-8118
Scheduled Actual Inspection Type Inspection No. Inspection Primary Inspector Reinspection Inspection
Date Start Date
Thursday, July 1, 2021
Checklist Item
BLDG-Building Deficiency
BLDG-Plumbing Final
BLDG-Mechanical Final
BLDG-Structural Final
BLDG-Electrical Final
COMMENTS
Status
Passed
Yes
Yes
Yes
Yes
Yes
Page 3 of 3
PERMIT INSPECTION HISTORY for (CBR2020-0234)
Permit Type: BLDG-Residential Application Date: 01/30/2020 Owner: COOWNER ZIMMERMAN JOSEPH P &
ZIMMERMAN SHIRLEY R
Work Class: Pool Issue Date: 02/25/2020 Subdivision: LA COSTA SOUTH UNIT #4
Status:
Scheduled
Date
04/29/2021
05/14/2021
07/01/2021
Closed -Finaled Expiration Date: 11/10/2021
IVR Number: 24528
Address: 2656 LEVANTE ST
CARLSBAD, CA 92009-8118
Actual Inspection Type
Start Date
Inspection No. Inspection
Status
Primary Inspector Reinspection Inspection
Checklist Item
BLDG-Building Deficiency
COMMENTS
February 24, 2020:(Virtual inspection).
(No building deficiencies).
1. Pool underground water leak test-pool
plumbing pipe pressure work-approved.
2. Underground gas line, with tracer wire,
with approved poly propylene gas pipe,
and rigid riser, under leak air pressure test
with gauge, scope of work-approved.
3. underground sewer plumbing line pipe
shaded correctly, and entire scope of
underground plumbing pipe and electrical
conduit work-approved.
04/29/2021 BLDG-54 Equipotential 156166-2021 Passed Tony Alvarado
Bond(Pools)
Checklist Item
BLDG-Building Deficiency
COMMENTS
April 29, 2021
No swimming pool/building deficiencies.
1. New completed Equipotential pool bond
scope of work at four points of copper
wire, located around perimeter pool.
2. additional perimeter equipotential pool
bond copper wire verified and connected
to (e) equipotential stubbed-out locations
around perimeter of pool-approved
05/14/2021 BLDG-55 157414-2021 Passed Tony Alvarado
Fence/Preplaster
Checklist Item
BLOG-Building Deficiency
COMMENTS
May 14, 2021: (Virtual inspection).
(No swimming pool/building deficiencies).
Scope of pre-plaster work-approved.
1. Perimeter yard fencing, side yard gates,
and doors with alarms leading out to pool
area, scope of work-approved.
2. Equipotential pool bond wire verified at
(4)-connection areas at pool perimeter
location points around pool, equipotential
pool bond wire surrounding entire
perimeter of swimming pool-verified and
approved.
3. Swimming pool light fixtures,
blue-bonding material installed and verified.
07/01/2021 BLDG-Final lnspactlon 160924-2021 Passed Tim Kersch
Passed
Yes
Complete
Passed
Yes
Complete
Passed
Yes
Complete
Thursday1 July 1, 2021 Page 2 of 3
Building Permit Inspection History Finaled
(cityof
Carlsbad
PERMIT INSPECTION HISTORY for (CBR2020-0234)
Permit Type: BLDG-Residential Application Date: 01/30/2020 Owner: COOWNER ZIMMERMAN JOSEPH P &
ZIMMERMAN SHIRLEY R
Work Class: Pool Issue Date: 02/25/2020 Subdivision: LA COSTA SOUTH UNIT #4
Status: Closed -Finaled Expiration Date: 11/10/2021
IVR Number: 24528
Address: 2656 LEVANTE ST
CARLSBAD, CA 92009-8118
Scheduled Actual Inspection Type Inspection No. Inspection Primary Inspector
Date Start Date Status
03/10/2020 03/10/2020 BLDG-SW-Pre-Con 121807-2020
COMMENTS
Passed Tony Alvarado
02/08/2021
02/09/2021
02/2412021
Checklist Item
BLDG-Building Deficiency March 10, 2020 -informed contractor
representative (Jose), regarding SWPP's
and BMP's-erosion control measures intact.
02/08/2021 BLDG-51 149980-2021 Passed Tony Alvarado
Excav/Steel(Pools)
Checklist Item
BLOG-Building Deficiency
COMMENTS
February 8, 2021: (virtual inspection)
(No Building deficiencies).
1. Pool excavation, steel reinforcement
rebar, per pool structural engineering detail
and specifications far Pool wall up-slope
surcharge engineering details, scope of
work-approved.
02/09/2021 BLDG-21 150149-2021 Partial Pass Tony Alvarado
Underground/Underflo
or Plumbing
Checklist Item
BLDG-Building Deficiency
COMMENTS
February 9. 2021. (Virtual inspection).
No building deficiencies.
1. Verified underground pool plumbing,
under water leak pressure test with
gauge, per engineers plans and detail
specifications-approved.
02/24/2021 BLDG-52 Pool Plumbing 151332-2021 Passed Tony Alvarado
Checklist Item
BLDG-Building Deficiency
COMMENTS
February 24, 2020:(Virtual inspection).
(No building deficiencies).
1. Pool underground water leak test-pool
plumbing pipe pressure work-approved.
2. Underground gas line, with tracer wire,
with approved poly propylene gas pipe,
and rigid riser, under leak air pressure test
with gauge, scope of work-approved.
3. underground sewer plumbing line pipe
shaded correctly, and entire scope of
underground plumbing pipe and electrical
conduit work-approved.
BLDG-53
Elec/Condult/Wlrlng(Po
ols)
151333-2021 Passed Tony Alvarado
Thursday, July 1, 2021
Reinspection Inspection
Complete
Passed
Yes
Complete
Passed
Yes
Reinspectlon Incomplete
Passed
Yes
Complete
Passed
Yes
Complete
Page 1 of 3
STORM WATER POLLUTION PREVENTION NOTES
1. ALL NECESSARY EQUIPMENT AND MATERIALS SHALL BE
AVAILABLE ON SITE TO FACILITATE RAPID INSTALLATION
OF EROSION AND SEDIMENT CONTROL BMPs WHEN RAIN
IS EMINENT.
2. THE OWNER/CONTRACTOR SHALL RESTORE ALL EROSION
CONTROL DEVICES TO WORKING ORDER TO THE SATISFACTION
OF THE CITY INSPECTOR AFTER EACH RUN-OFF PRODUCING
RAINFALL.
3. THE OWNER/CONTRACTOR SHALL INSTALL ADDITIONAL EROSION
CONTROL MEASURES AS MAY BE REQUIRED BY THE CITY .
INSPECTOR DUE TO INCOMPLETE GRADING OPERATIONS OR
UNFORESEEN CIRCUMSTANCES WHICH MAY ARISE.
4. ALL REMOVABLE PROTECTIVE DEVICES SHALL BE IN PLACE
AT THE END OF EACH WORKING DAY WHEN THE FIVE (5)
DAY RAIN PROBABILITY FORECAST EXCEEDS FORTY PECENT
(40%). SILT AND OTHER DEBRIS SHALL BE REMOVED AFTER
EACH RAINFALL.
5. ALL GRAVEL BAGS SHALL CONTAIN 3/4 INCH MINIMUM
AGGREGATE.
6. ADEQUATE EROSION AND SEDIMENT CONTROL AND PERIMETER
PROTECTION BEST MANAGEMENT PRACTICE MEASURES MUST
BE INSTALLED AND MAINTAINED.
7. THE CITY INSPECTOR SHALL HAVE THE AUTHORITY TO ALTER
THIS PLAN DURING OR BEFORE CONSTRUCTION AS NEEDED
TO ENSURE COMPLIANCE WITH CITY STORM WATER QUALITY
REGULATIONS.
OWNER'S CERTIFICATE:
I UNDERSTAND AND ACKNOWLEDGE THAT I MUST: (1) IMPLEMENT
BEST MANAGEMENT PRACTICES (BMPS) DURING CONSTRUCTION
ACTIVITIES TO THE MAXIMUM EXTENT PRACTICABLE TO AVOID
THE MOBILIZATION OF POLLUTANTS SUCH AS SEDIMENT AND TO
AVOID THE EXPOSURE OF STORM WATER TO CONSTRUCTION
RELATED POLLUTANTS; AND (2) ADHERE TO, AND AT ALL TIMES,
COMPLY WITH THIS CITY APPROVED TIER 1 CONSTRUCTION SWPPP
THROUGHOUT THE DURATION OF THE CONSTRUCTION ACTIVITIES
· UNTIL THE CONSTRUCTION WORK IS COMPLETE AND APPROVED
BY THE CITY OF CARLSBAD.
M1c,\...t.A c~~
lY_NE~'S AGENT NAME (PRINT
l I µ,/-z.,,
LJATE
E-29
STORM WATER COMPLIANCE FORM
TIER 1 CONSTRUCTION SWPPP (6f<d0d() -{)22'-f
BEST MANAGEMENT PRACTICES (BMP) SELECTION TABLE
Erosion Control Sediment Control BMPs Tracking Non-Storm Water Waste Management and Materials
BMPs Control BMPs Management BMPs Pollution Control BMPs
C -C C .Q -0 0 C
"O :;:, :;:, -Q) "O C
"' C c> 0 E C Q) "O 0 0 C C c> E C -0 C, C, .Q ·c a. 0
0 E -L L '6 Q) 0
Q) -L ·3 ::,; "O "' c> L --C '-~ c>
C Q) L .5 Q) C: "' "' "' ~ ·c CT 0 C c> Oo a. Q) "E -C <n C L w Q) C 0
Best Management Practice* ~ .5 0 [D a. 0 Q) 0 L (..') Q) > :;:,
"'3' "' ,'= Q) 0 C u Q) -~ Q) 0 -.c C E UL "' ~ "O "' ::,; C Q) C
(BMP) Description ➔ "' 0 Q) (/) ·a "' c> Q) c> [D •o C c> C "O "' C 0 ::::, !!? -Q) Q) 3 ~ Q)
Q) -0 =g 0 3' C L 0 ~~ "O >, 0"' Cc 0 c> [!J E ~ L 0 C 0 [D (I)•-c> D:;:; 0 0 Q) Q) ::,; 0 c> 0 C _E ~o u Q) E 8' 0 X Q) 0:: 0 ~~ 0 en:;:; Q) ~ .s a_ L-3: Q)
0 Q) E f;l :=3: Cl. 0
Q) Q) u.. E _,. g! Q) C, .0 L•-cO :0 UC LO ·c _,. L c> -"O .C C 0 L "O :c ~ :0 -g 20 0 Q) "O 0
' 0 t·a g-'6 Q) Q) C, L-•-L ·-0 Q) L 0 --0 -Q) e LO C 00 0 c> .8 0 00 ~ ~ -.c Q) -o -0 = C: •-C
Q) ~ OL en Q) .c .0 -o 0 -L Cl) C 3: ct 0 ~u o_ 0 -a. 0 oo
(..') WO en ' (/) u Ll:: (..') v,> (/) (/) Cl. (/) 0:: Cl.0 a. ::,; (/) ::,; (/) (1)0 (/)::,;
CASQA Designation ➔ r--00 a, ~ ,,, .... "' <D 00 0 N ,,, r--00 N ,,, .... "' 'T 'T r--'T 'T 'T 'T I I I I I I I I I I I I I I I I I
u u u u w w w w w w w w f!:: f!:: (/) (/) (/) (/) ::,; "' ~ ~ ~ Construction Activity w w w w (/) (/) (/) (/) (/) (/) (/) (/) :z z z z 3: 3:
/ Gradinn /Soil Disturbance V IX
, / Trench inn /Excavation ,/ Iv
I/ Stocknilinn . X:
Drillinn 1Aorino
/ Concrete/Asnhalt Sawcuttinn
I" Concrete Flatwork
/ Pavina
Conduit/Pioe Installation
Stucco/Mortar Work
/ Waste Disoosal V
Staainn /Lav Down Area
Enuinment Maintenance and Fuelina
Hazardous Substance Use/Storaoe
Dewaterino
Site Access Across Dirt
other flistl:
Instructions: 1. Check the box to the left of all applicable construction activity (first column) expected to occur during construction.
2. Located along the top of the BMP Table is a list of BMP's with it's corresponding California Stormwater Quality Association (CASQA) designation number. Choose one
or more BMPs you intend to use during construction from the list. Check the box where the chosen activity row intersects with the BMP column.
3. Refer to the CASQA construction handbook for information and details of the chosen BMPs and how to apply them to the project.
PROJECT INFORMATION
Site Address: 'Jb5"b {.,€Vw,te st-
Assessor's Parcel Number: ~l.b -d,;)..O -~s-w
Emergency Contact:
Name: £tw-,e(' \1a,\t
24 Hour Phone: "!,bf) -l{").(._... tCtfi.,
Construction Threat to Storm Water Quality
(Check Box)
~EDIUM □ LOW
Q) -"' 0 3:-C
"' Q) => E 0 Q) "O c> 5o NC 00
::,: "'
<D I ~
Q) -"' o-3: ii ., E
-Q) Q) c> ho
cc oo u:::e
00 I ~
.
V .:;
V>
.
Page 1 of 1 REV 11 /17