HomeMy WebLinkAbout1923 CALLE BARCELONA; 139; CBC2021-0152; PermitPERMIT REPORT
(City of
Carlsbad
Commercial Permit
Print Date: 03/24/2022 Permit No: CBC2021-0152
Job Address: 1923 CALLE BARCELONA, # 139, CARLSBAD, CA 92009-8457 Status: Closed -Finaled
Permit Type: BLDG-Commercial Work Class: Tenant Improvement
Parcel#: 2550120400 Track#:
Valuation: $79,067.00 Lot#:
Occupancy Group: M
#of Dwelling Units:
Bedrooms:
Bathrooms:
Project Title:
Project#:
Plan#:
Construction Type:111B
Orig. Plan Check#:
Plan Check#:
Applied: 04/28/2021
Issued: 12/13/2021
Finaled Close Out: 03/24/2022
Inspector:
Final Inspection:
TAlva
12/16/2021
Description: WARBY PARKER (JAND INC.): Tl RETAIL TO RETAIL-PARTITIONS, FIXTURES, HVAC INTERIOR ONLY (1700 SF)
FEE
BUILDING PLAN CHECK FEE (BLDG)
BUILDING PERMIT FEE ($2000+)
Property Owner:
T-C FORUM AT CARLSBAD LLC
4675 MACARTHUR CT, # 110
NEWPORT BEACH, CA 92660
ELECTRICAL BLDG COMMERCIAL NEW/ADDITION/REMODEL
581473 GREEN BUILDING STATE STANDARDS FEE
STRONG MOTION-COMMERCIAL
MECHANICAL BLDG COMMERCIAL NEW/ADDITION/REMODEL
Total Fees: $1,047.27 Total Payments To Date: $1,047.27
Contractor:
E AND H CONSTRUCTION CO INC
30110 CROWN VALLEY PKWY, # STE 106
LAGUNA NIGUEL, CA 92677-2043
(949) 248-5444
Balance Due:
AMOUNT
$377.23
$538.90
$60.00
$4.00
$22.14
$45.00
$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.
1635 Faraday Avenue, Carlsbad, CA 92008-7314 I 760-602-2700 I 760-602-8560 f I www.carlsbadca.gov
Ccicyof
Carlsbad
COMMERCIAL
BUILDING PERMIT
APPLICATION
B-2
Plan Check Cf:,C,,2Qz/.0/:5?-
Est. Value ?'£ 000
PC Deposit /
Date 4 :=)t5];)..J T'
D Addition/New: New SF and Use,, ________ New SF and Use,
___ Deck SF,'-----Patio Cover SF (not lndudlngflatwork)
~IIIIPIDll8ffleffl: (Joo SF,
____ SF,
Existing Use,...JL(Y\_,___ ___ Proposed Use _k\..,_,.__ __ _
Existing Use Proposed Use ____ _
D Pool/SIN!· SF Additional Gas or Electrical Features? ________ _
0 Solar: KW,, _ __!Modules,.___-'Mounted, Tilt e/ r:, RMA: e /r;;a, Panel UPSl'llde: ~~
D Pl1111lllln(IMechanlc/flectrka!Only: __________________ _
□ Other:
1635 Faraday Ave cartsbad, CA 92008
B-2
Ph: 760-602-2719 Fax: 760-602-8558 Email: Building@carlsbadca.gov
PAnA 1 nf!>
IDENTIFY WHO WILL PERFORM THE WORK BY COMPlETING fOPTION A) OR (OPTION 8) 8£LOW:
(OPTION A): LICENSED COlmlAqoa DEC1ARATIOtt
I hereby af/lrm under penalty of perjury that I am licensed under provisions of O,apter 9 (commencing with Section
1000) of DMslon 3 of the Business and Professions Code, and my license is In full force and effect. I also affirm under
penalty of perjury one of the following declarations:
-g{'haveandwlU-a c:aUllw•ol-tose!Hnsun, 1or-.., compensation pn,vlded by Socllon3700ofthe illllllrCode lorthe pem,rmana, of lhe-kwNchtlupermitlslssued.....,Ne. ___________________ '
✓._ andwll-•-•-Uon, asraq-bySedlon 370Dof the labor Code, forthe~pe~ of thewwkforwhldl this penntt 1$ ,-. • M'/-.--.1~9 •~-and.JIOll<vnumberara:lns~-: __: __ u,~ /-VSi(A,ll>vf:c fu:0 "'""'No. -/J'f ?,t) -r -Z.0 ~ bpi,-,, DIiie: CN -z;;. 'V'
0 Certffkataollilcemptlon: I cenlfythat In lheporfc. .. w...e ol lhe wwtt lor whkt, !Iii$ permit I$ Issued, I shall not emploV any panan In any manner so as to
lieClome511bject1Dlhe__....,.__,Lowsof~W-:Fdn1o.._-..., .. pe,u--ll---sultjactan .......,.. .. _...,__dvtl_...,1o$1-.--,1n-111etothecostof __ , ___ ,,_...forln-il'IOllofthe ....... -. ........... __,,._
CONSTIWg]ON LENDING AGENCY. IF ANY:
I """-by alllnn thattliere ls a -•-.-far the perfurmonce of the WOif< this pem,lt Is IMued (Sec. 3097 Pl CMJ Code).
-·-.,,■•,-~
CONTRACTOR PRINT: M(lrtit'( 1z* l'·~· SIGN: 1:t:u;;; t,+--DATE: *" e~ ,1/
fOPTION Bl: OWNG-8UllDER DECI.ARATJON:
, ,,.,., .,,,,,,,_ lam .,,,.,.,.t/,~ .. Co.:Oo.:llir's --Jo, the ft>IIOMIJJ-
O~ •-oflhe pr-1J cw my emplayees lllld:-•their ool. W1ape:-., wllldothe-andthestruclun!lsnot.__oraffered far-(Sec.
-,..__.Prof I ••-•-•-Law-nc:taJlll)flc> ... _ol~whal:ulldsorlmpn,vesthereon,andwhadoessudl --•lli:Di.wh hlaOMI e:nplu.-""""41N __, lmpo .. -are not llllended..--., ror-.11. _,, Ille bulldlni, or lmJ)ro,eme,~ Is dlwf!Hn--ol....-., the_.-llulklerwllhavethe burdeftof proving that he did notbullcl or,-1or111e ....,,....o1sa1e~
01t •ownerafthe~,am 8'1'tirstlel\' contracllng wfth IICllmed comractors to construct the project (Sec. 7044, Business n r:of lull Code: The
-•llcemat.aw-notepjllrtoan-orp,_iyw1:obulfclso,Jmpn,ves-.anc1comramforsudlpn:,Jedswllhcontn;d«fsl
-purwanttothe CcJntrac:tD,'s Ucema law).
01am-,,pt--andl':-1SCodo-3,Chapler9,Arlldo3farthlsmson,
a...,_,_,....., 1 ............ IJ •• tl.•1fontr"hasbeen flied out. slaned andattac:hedtothisappllcatlon. Proofofidenttft 1f allttac.'Md.
D -....•-.1wt1Ai1omFonn"hasbeenlihd-sta,,edandattachedto lhlsopplkadonglvlngthe.__,,,,,,,_ doe-onlheownerbehalf,
Proof oft la1illlcalfo1t .attadled..
~my-below! adlnowledee lllat.-for my-1 residencaln wbich I musthave N!Slded forot least one yeor priortoa,mplelion o11he "-"'"""r.overed by 1111s pannlt, I cannotleaallY sell •stn:<:ture that I haw built as an _-builder W It has not been c:onstrucled In !ti entirety by licensed
CCWltr:aduu.l 5 J1Zi:dt#Jat11a,wo/tlttt: ,,. tklow.Sedlon10f4a/tbeBusmffsond."tJJ:f I I JS~isavaildileupon,equest-'tendlisappllt:otlonls
JJbftltted orot dwfol/OWklf W.slte: hap:/A11tm'e,J fu,.:o4'W/a,low.htmL
OWNER PRINT: ___________ SIGN:, ________ DATE: _____ _
Al'PUCMft' CERTIFICATION: SIGNATURE REQUIRED AT THE TIME Of SUBMITTAL
S,my ~below, I~ dlot: lam lhe _,,,,,_,,,,. _ o/Ca1/forlila l1amsed Con-or...-«J ID act on the prope,ty
_,.,,...,.,,,,,.,.,,,, llel:alf, ICll!rtfj, dlotl ,,_, rmd theflPP/katian udd-thattM abowl ~ ls r:omctond that die
/IJfo,motlon on die plllnsts Ot"c:IIRlle. lllll'ftlDcomp/jl_, an crty otdfnances and Statelaws ,e/otlng ID bUlltJlr,g <'OMtructlon.
l hftll,"""-"""_,illlt11,,,"1llle Qlro/°"""'1dto _.upon lhe abrM!m«>Qan«/p,,:rp«tyfr,, A--..,...,,-. IALSOA6/IEE10SAVI;;
tNDEMNlff AND llliEP Htllt1'3 THI/ a,ra,: OW SMD-fNST AU.~ .JI.JtJGll,IElf mrJSANDEX/IENSES WHICH MA.YINAN'f WAY
NX1IJJE AfiAI/IISTSA/DctrY IIICJ1NSEQJBiaOF 1HE GIIANTIN6 OF THIS l'fJIN/fT. OSHA: An OSHA ,..,-mlt Is Rlf/llln,djbr """'1IIJtlor aver 5'0'
deepor:ddemolltlo,1or_of_averJ$fot/esln/lell1hf-
APPUCANT PRINT: 1"'" ;ua,ut-'z1 ' SIGN: / ¥//\1)ay;eg DATE: ~-22-A/
1635 Faraday Ave cartsbad, CA 92008 Ph: 760-602-2719 Fax: 760-602-8558 Email: Bulldlng@car1sbadca.gov
IL?
PERMIT INSPECTION HISTORY for (CBC2021-0152)
Permit Type: BLDG-Commercial
Work Class: Tenant Improvement
Status: Closed -Finaled
Application Date: 04/28/2021 Owner: T-C FORUM AT CARLSBAD LLC
Issue Date: 12/13/2021 Subdivision: CARLSBAD TCT#92-08 GREEN
Expiration Date: 06/15/2022
IVR Number: 33075
VALLEY
Address: 1923 CALLE BARCELONA, # 139
CARLSBAD, CA 92009-8457
Scheduled Actual Inspection Type Inspection No. Inspection Primary Inspector Reinspection Inspection
Date Start Date
Checklist Item
BLDG-Building Deficiency
Thursday, March 24, 2022
Status
COMMENTS
December 16, 2021:
1. New mechanical HVAC system, test and
air balance report Verified, scope of
Mechanical work-approved.
Passed
Yes
Page 5 of 5
PERMIT INSPECTION HISTORY for (CBC2021-0152)
Permit Type: BLDG-Commercial
Work Class: Tenant Improvement
Status:
Scheduled
Date
12/16/2021
12/1712021
Closed -Finaled
Actual Inspection Type
Start Date
BLDG-Electrical Final
12/1612021 BLDG-Final Inspection
Checklist Item
BLDG-Structural Final
BLDG-Structural Final
12/17/2021 BLDG-43 Air
Cond./Furnace Set
Thursday, March 24, 2022
Application Date: 04128/2021
Issue Date: 12113/2021
Owner: T-C FORUM AT CARLSBAD LLC
Subdivision: CARLSBAD TCT#92-08 GREEN
VALLEY
Expiration Date: 06/15/2022
IVR Number: 33075
Address: 1923 CALLE BARCELONA, # 139
CARLSBAD, CA 92009-8457
Inspection No. Inspection
Status
December 14, 2021:
Primary Inspector
1. Tenant improvement Remodel and
Deficiencies, scope of work not ready.
2. Air balance mechanical test report
required, informed project manager.
3. ADA compliant restroom-not ready.
a) ADA restroom Circular or triangular door
signage not installed.
b) ADA braille wall square sign not
installed, latch side of door, max height 48"
inches high from bottom of braille lettering.
c) Max sink height cannot exceed 34"
inches max.
d) toilet dispenser Height-max 40" inches.
Contractor installed ADA restroom sink at
34-1/2",inches total height-not approved.
4. Fire department final clearance required
prior to final building inspection. Informed
contractor representative Eric.
172860-2021
COMMENTS
Passed
December 16, 2021:
Tony Alvarado
1. Verified final air Test and balance
Mechanical Report N approved.
2. All correction notices requirements,
addressed and completed per approved
plans-approved.
December 14, 2021:
1. Tenant improvement Remodel and
Deficiencies, scope of work not ready.
2. Air balance mechanical test report
required, informed project manager.
3. ADA compliant restroom-not ready.
a) ADA restroom Circular or triangular door
signage not installed.
b) ADA braille wall square sign not
installed, latch side of door, max height 48"
inches high from bottom of braille lettering.
c) Max sink height cannot exceed 34"
inches max.
d) toilet dispenser Height-max 40" inches.
Contractor installed ADA restroom sink at
34-1/2",inches total height-not approved.
4. Fire department final clearance required
prior to final building inspection. Informed
contractor representative Eric.
172995-2021 Passed Tony Alvarado
Reinspection Inspection
No
Complete
Passed
Yes
No
Complete
Page 4 of 5
PERMIT INSPECTION HISTORY for (CBC2021-0152)
Permit Type: BLDG-Commercial
Work Class: Tenant Improvement
Status:
Scheduled
Date
Closed -Finaled
Actual Inspection Type
Start Date
BLDG-Mechanical Final
BLDG-Structural Final
Thursday, March 24, 2022
Application Date: 04/28/2021
Issue Date: 12/13/2021
Owner: T-C FORUM AT CARLSBAD LLC
Subdivision: CARLSBAD TCT#92-08 GREEN
VALLEY
Expiration Date: 06/15/2022
IVR Number: 33075
Address: 1923 CALLE BARCELONA, # 139
CARLSBAD, CA 92009-8457
Inspection No. Inspection
Status
December 14, 2021:
Primary Inspector
1. Tenant improvement Remodel and
Deficiencies, scope of work not ready.
2. Air balance mechanical test report
required, informed project manager.
3. ADA compliant restroom-not ready.
a) ADA restroom Circular or triangular door
signage not installed.
b) ADA braille wall square sign not
installed, latch side of door, max height 48"
inches high from bottom of braille lettering.
c) Max sink height cannot exceed 34"
inches max.
d) toilet dispenser Height-max 40" inches.
Contractor installed ADA restroom sink at
34-1/2",inches total height-not approved.
4. Fire department final clearance required
prior to final building inspection. Informed
contractor representative Eric.
December 14, 2021:
1. Tenant improvement Remodel and
Deficiencies, scope of work not ready.
2. Air balance mechanical test report
required, informed project manager.
3. ADA compliant restroom-not ready.
a) ADA restroom Circular or triangular door
signage not installed.
b) ADA braille wall square sign not
installed, latch side of door, max height 48"
inches high from bottom of braille lettering.
c) Max sink height cannot exceed 34"
inches max.
d) toilet dispenser Height-max 40" inches.
Contractor installed ADA restroom sink at
34-1/2",inches total height-not approved.
4. Fire department final clearance required
prior to final building inspection. Informed
contractor representative Eric.
Reinspection Inspection
No
No
Page 3 of 5
PERMIT INSPECTION HISTORY for (CBC2021-0152)
Permit Type: BLDG-Commercial
Work Class: Tenant Improvement
Status: Closed -Finaled
Application Date: 04/28/2021
Issue Date: 12/13/2021
Expiration Date: 06/15/2022
IVR Number: 33075
Owner: T-C FORUM AT CARLSBAD LLC
Subdivision: CARLSBAD TCT#92-08 GREEN
VALLEY
Address: 1923 CALLE BARCELONA, # 139
CARLSBAD, CA 92009-8457
Scheduled
Date
Actual Inspection Type
Start Date
Inspection No. Inspection
Status
Primary Inspector Reinspection Inspection
Checklist Item
BLDG-Building Deficiency
BLDG-Plumbing Final
Thursday, March 24, 2022
COMMENTS
December 14, 2021:
1. Tenant improvement Remodel and
Deficiencies, scope of work not ready.
2. Air balance mechanical test report
required, informed project manager.
3. ADA compliant restroom-not ready.
a) ADA restroom Circular or triangular door
signage not installed.
b) ADA braille wall square sign not
installed, latch side of door, max height 48"
inches high from bottom of braille lettering.
c) Max sink height cannot exceed 34"
inches max.
d) toilet dispenser Height-max 40" inches.
Contractor installed ADA restroom sink at
34-1/2",inches total height-not approved.
4. Fire department final clearance required
prior to final building inspection. Informed
contractor representative Eric.
December 14, 2021:
1. Tenant improvement Remodel and
Deficiencies, scope of work not ready.
2. Air balance mechanical test report
required, informed project manager.
3. ADA compliant restroom-not ready.
a) ADA restroom Circular or triangular door
signage not installed.
b) ADA braille wall square sign not
installed, latch side of door, max height 48"
inches high from bottom of braille lettering.
c) Max sink height cannot exceed 34"
inches max.
d) toilet dispenser Height-max 40" inches.
Contractor installed ADA restroom sink at
34-1/2",inches total height-not approved
4. Fire department final clearance required
prior to final building inspection. Informed
contractor representative Eric.
Passed
No
No
Page 2 of 5
Building Permit Inspection History Finaled
( City of
Carlsbad
Permit Type:
Work Class:
Status:
Scheduled
Date
10/12/2021
11/03/2021
11/09/2021
12/14/2021
PERMIT INSPECTION HISTORY for (CBC2021-0152)
BLDG-Commercial
Tenant Improvement
Closed -Finaled
Application Date: 04/28/2021
Issue Date: 12/13/2021
Expiration Date: 06/15/2022
IVR Number: 33075
Owner: T-C FORUM AT CARLSBAD LLC
Subdivision: CARLSBAD TCT#92-08 GREEN
VALLEY
Address: 1923 CALLE BARCELONA, # 139
CARLSBAD, CA 92009-8457
Actual Inspection Type Inspection No. Inspection Primary Inspector Reinspection Inspection
Start Date Status
10/12/2021 BLDG-44 168283-2021 Passed Tony Alvarado
Rough/Ducts/Dampers
Checklist Item
BLDG-Building Deficiency
COMMENTS
October 12, 2021:
1. No mechanical ductwork deficiencies.
2. New mechanical tenant improvement
ducting, duct sealant applied at all
connections of rigid metal duct work -
approved.
11/03/2021 BLDG-84 Rough
Combo(14,24,34,44)
169978-2021 Passed Tim Kersch
Checklist Item
BLDG-Building Deficiency
BLDG-14
Frame-Steel-Bolting-Welding
(Decks)
BLDG-24 Rough-Topout
BLDG-34 Rough Electrical
BLDG-44
Rough-Ducts-Dampers
COMMENTS
11/09/2021 BLDG-17 Interior
Lath/Drywall
170407-2021 Passed Tony Alvarado
Checklist Item
BLDG-Building Deficiency
COMMENTS
November 9, 2021:
No drywall/gypsum board Deficiencies.
1. Interior tenant improvement, no
non-loadbearing structural modifications,
Gypsum/drywall; type, size, and anchoring
schedule attachment-approved.
12/1412021 BLDG-Final Inspection 172608-2021 Failed Tony Alvarado
Complete
Passed
Yes
Complete
Passed
Yes
Yes
Yes
Yes
Yes
Complete
Passed
Yes
Reinspection Incomplete
Thursday, March 24, 2022 Page 1 of 5
DATE: 06/08/2021
JURISDICTION: Carlsbad
PLAN CHECK#.: CB-CBC2021-0152
✓• EsG1I
SET II
PROJECT ADDRESS: 1923 Calle Barcelona 139B
PROJECT NAME: TI WARBY PARKER
□ APPLICANT
□ JURIS.
~ The plans transmitted herewith have been corrected where necessary and substantially comply
with the jurisdiction's building codes.
D The plans transmitted herewith will substantially comply with the jurisdiction's codes
when minor deficiencies identified below are resolved and checked by building department staff.
D The plans transmitted herewith have significant deficiencies identified on the enclosed check list
and should be corrected and resubmitted for a complete recheck.
D The check list transmitted herewith is for your information. The plans are being held at EsGil
until corrected plans are submitted for recheck.
D The applicant's copy of the check list is enclosed for the jurisdiction to forward to the applicant
contact person.
D The applicant's copy of the check list has been sent to:
Lyn Davies
~ EsGil staff did not advise the applicant that the plan check has been completed.
D EsGil staff did advise the applicant that the plan check has been completed.
Person contacted: Lyn Davies Telephone#: 616-493-9326
Date contacted: (by: ) Email: lynd@precisionpermits.com
Mail Telephone
0 REMARKS:
By: Steven Miller
EsGil
Fax In Person
Enclosures:
05/19
9320 Chesapeake Drive, Suite 208 ♦ San Diego, California 92123 ♦ (858) 560-1468 ♦ Fax (858) 560-1576
•
DATE: 05/19/2021
JURISDICTION: Carlsbad
PLAN CHECK#.: CB-CBC2021-0152
✓• EsG1I
A SAFEbuilt Compilny
SETI
PROJECT ADDRESS: 1923 Calle Barcelona 1398
PROJECT NAME: TI WARBY PARKER
□ APPLICANT
□ JURIS.
D The plans transmitted herewith have been corrected where necessary and substantially comply
with the jurisdiction's codes.
D The plans transmitted herewith will substantially comply with the jurisdiction's codes
when minor deficiencies identified below are resolved and checked by building department staff.
D The plans transmitted herewith have significant deficiencies identified on the enclosed check list
and should be corrected and resubmitted for a complete recheck.
~ The check list transmitted herewith is for your information. The plans are being held at EsGil
until corrected plans are submitted for recheck.
D The applicant's copy of the check list is enclosed for the jurisdiction to forward to the applicant
contact person.
~ The applicant's copy of the check list has been sent to:
Lyn Davies
D EsGil staff did not advise the applicant that the plan check has been completed.
~ EsGil staff did advise the applicant that the plan check has been completed.
Person contacted: Lyn Davies Telephone#: 616-493-9326
Date contacted: (by: ) Email: lynd@precisionpermits.com
Mail Telephone
0 REMARKS:
By: Steven Miller
EsGil
Fax In Person
Enclosures:
05/19
9320 Chesapeake Drive, Suite 208 ♦ San Diego, California 92123 ♦ (858) 560-1468 ♦ Fax (858) 560-1576
' '
CARLSBAD CBC2021-0152
., 05/18/2021
PLAN REVIEW CORRECTION LIST
COMMERCIAL
PLAN CHECK#.: CB-CBC2021-0152
OCCUPANCY: M
TYPE OF CONSTRUCTION: IIIB
ALLOWABLE FLOOR AREA: 37,500
SPRINKLERS?: YES
REMARKS:
DATE PLANS RECEIVED BY
JURISDICTION: 04/28/2021
DATE INITIAL PLAN REVIEW
COMPLETED: 05/19/2021
FOREWORD (PLEASE READ):
JURISDICTION: Carlsbad
USE: Retail
ACTUAL AREA: 1 700 sq ft
STORIES: No Change
HEIGHT: No Change
OCCUPANT LOAD: 23
DATE PLANS RECEIVED BY
ESGIL CORPORATION: 04/29/2021
PLAN REVIEWER: Steven Miller
This plan review is limited to the technical requirements contained in the California version of
the International Building Code, Uniform Plumbing Code, Uniform Mechanical Code, National
Electrical Code and state laws regulating energy conservation, noise attenuation and access for
the disabled. This plan review is based on regulations enforced by the Building Department.
You may have other corrections based on laws and ordinances enforced by the Planning
Department, Engineering Department, Fire Department or other departments. Clearance from
those departments may be required prior to the issuance of a building permit.
Code sections cited are based on the 2019 CBC, which adopts the 2018 IBC.
The following items listed need clarification, modification or change. All items must be satisfied
before the plans will be in conformance with the cited codes and regulations. Per Sec. 105.4 of
the 2018 International Building Code, the approval of the plans does not permit the violation of
any state, county or city law.
To speed up the recheck process, please note on this list (or a copy) where each
correction item has been addressed, i.e., plan sheet number, specification section, etc.
Be sure to enclose the marked up list when you submit the revised plans.
, ' CARLSBAD CBC2021-0152
05/18/2021
NOTICE: CITY AND ESGIL'S HOURS OF OPERATION ARE AFFECTED BY
THE CURRENT COVID-19 EPIDEMIC. PLAN REVIEWER MAY NOT BE
AVAILABLE TO ANSWER QUESTIONS BY PHONE, BUT MAY BE
REACHED BY E-MAIL AT stmiller@esgil.com . (858) 225-2775
GENERAL
1. Please make all corrections, as requested in the correction list. Submit FOUR new
complete sets of plans for commercial/industrial projects (THREE sets of plans for
residential projects). For expeditious processing, corrected sets can be submitted
in one of two ways:
1. Deliver all corrected sets of plans and calculations/reports directly to the City of
Carlsbad Building Department, 1635 Faraday Ave., Carlsbad, CA 92008, (760)
602-2700. The City will route the plans to EsGil and the Carlsbad Planning,
Engineering and Fire Departments.
2. Bring TWO corrected set of plans and calculations/reports to EsGil, 9320
Chesapeake Drive, Suite 208, San Diego, CA 92123, (858) 560-1468. Deliver all
remaining sets of plans and calculations/reports directly to the City of Carlsbad
Building Department for routing to their Planning, Engineering and Fire
Departments.
NOTE: Plans that are submitted directly to EsGil only will not be reviewed by the
City Planning, Engineering and Fire Departments until review by EsGil is complete.
2. Plans may be submitted in electronic format, subject to the jurisdiction's
approval. If so, they must have restrictions removed from the security settings.
Electronic plans with restrictions to markups, printing, or stamping will not be
approved.
3. A reminder that due to Covid-19, the City will not permit counter corrections.
Please make sure all the items are satisfied; otherwise, another round of
corrections will be necessary.
PLANS
4. All sheets of the plans and the first sheet of the calculations are required to be
signed by the licensed architect, engineer, or the person responsible for the
plan's preparation. California State Law.
5. Please provide a signed copy of the Title 24 ADA Compliance sheet to page
T100 the Title page. Please see a copy of the Compliance Form at the end of the
list.
6. Page T100 Building Code Analysis the Mechanical code references the 2019
CBC and not the 2019 CMC. Please revise.
8. Page T100 The Sheets of the plans are out of order per the index of drawings.
Please revise so that the plans are in order per the index.
CARLSBAD CBC2021-0152
05/18/2021
9. Page A 101 Please reference the location of the partition wall construction details
on page A401 .
10. Page A 103 Room #6 Back of House. Please show that 5% of the lockers are
ADA compliant.
11. Provide a note on the plans indicating if any hazardous materials will be stored
and/or used within the building which exceed the quantities listed in IBC Tables
307.1(1) and 307.1(2).
PLUMBING
12. Page A 103 exam room #2. Please label or number the plumbing fixtures in this
room.
13. Page P-501 For the hot water recirculating loop system, (Not single-family
homes): please detail the following:
1.
2.
• The installation of an air release valve on the inlet side of the recirculation pump,
within 4' of the pump.
• A check valve is required between the recirculating pump and the water heating
equipment to prevent the hot water from flowing backwards through the recirculation
loop. Energy Code 110.3.(c).5.A
• A check valve is required on the cold-water supply line between the hot water system
and the next closest tee on the cold-water supply line per Energy Code 110.3.(c).5.F
(See CPC 608.3 for expansion tank requirements.)
• Show the required hose bibb installed between the water heater and isolation valve
(after the recirculation pump) per Energy Code 110.3.(c).5.C
• Show the required pump isolation valves (both on the inlet and outlet side) for the
recirculation pump per Energy Code 110.3.(c).5.D
ADDITIONAL
To speed up the review process, please note on this list (or a copy) where each
correction item has been addressed, i.e., plan sheet, note or detail number,
calculation page, etc.
Please indicate here if any changes have been made to the plans that are not a
result of corrections from this list. If there are other changes, please briefly
describe them and where they are located in the plans.
Have changes been made to the plans not resulting from this correction
list? Please indicate: □ Yes □ No
3. The jurisdiction has contracted with EsGil, located at 9320 Chesapeake Drive,
Suite 208, San Diego, California 92123; telephone number of 858/560-1468, to
perform the plan review for your project. If you have any questions regarding
these plan review items, please contact Steven Miller at Esgil. Thank you.
• ., ' CARLSBAD CBC2021-0152
• 05/18/2021
[DO NOT PAY -THIS IS NOT AN INVOICE]
VALUATION AND PLAN CHECK FEE
JURISDICTION: Carlsbad
PREPARED BY: Steven Miller
PLAN CHECK#.: CB-CBC2021-0152
DATE: 05/19/2021
BUILDING ADDRESS: 1923 Calle Barcelona 139B
BUILDING OCCUPANCY: M
BUILDING AREA Valuation
PORTION (Sq.Ft) Multiplier
Tl M Occupancy 1700 46.51
Air Conditioning
Fire Spririders
TOTAL VALUE
Jurisdiction Code CB By Ordinance
1997 USC Buildin 9 Permit Fee ..,
I 1997 use Plan Check Fee
I ~J hi:
Type of Review:
I Repetitr,e Fee
,-i -.., j Repeats
Comments:
J;;-Complete Review
r other
1 Hourly
EaGil Fee
Reg.
Mod.
VALUE ($)
79,067
79,067
r Structural Only
$347.101
Sheet 1 of 1
□ □ □ □ □ □ □ □ □ □
ENCINA WASTEWATER AUTHORITY
INDUSTRIAL WASTEWATER DISCHARGE PERMIT
SCREENING SURVEY
6200 Avenida Encinas, Carlsbad, CA 92011
Phone: 760-438-3941 Fax: 760-476-9852
SourceControl@encinajpa.com
Date: '-'/-;;2. 1 7 /
Busin-es_s_N_a_m_e_:~=-'-'Lv.::'...,Cc:.\.c.r.,,,b'-'f'i---,--',,/'-/.::c.:c.-l:..,:,.::lfJ"'-,-''-·f' ____ _,,.. _
Street Address: _,_I c .... l?,"'-"3'___,{..__11"-j .,_J/1-c__.~·r:-"-7-'("'-l-~-'=e.-'-/ _u_nc.:C\_J::t._ . .:.../. 3r1_8
Email Address: /y,1d Q{J(<;,<.!'2!0Av<;,rMi f,;,, {0.4'\
PLEASE CHECK HERE IF YOUR B~SINESS IS EX~MPT : (ON REVERSE SIDE CHECK TYPE OF BUSINESS)\li-7{
Check all below that are present at your facility: ¥J-'
Acid Cleaning
Assembly
Automotive Repair
Battery Manufacturing
Biofuel Manufacturing
Biotech Laboratory
Bulk Chemical Storage
Car Wash
Chemical Manufacturing
Chemical Purification
D Food Processing
D Glass Manufacturing
D Industrial Laundry
D Ink Manufacturing
D Laboratory
D Machining/Milling
D Membrane manufacturing D (i.e. waterfilter membranes)
D Metal Casting/Forming D Metal Fabrication
D Meta! Powders Forming D Nutritional SupplemenWitamin
D Manufacturing
D Painting/Finishing D Paint Manufacturing D Personal Care Products
D Manufacturing
O Pesticide Manufacturing/ Packaging
D Pharmaceutical Manufacturing D (including precursors)
D Dental Offices D Metal Finishing D Porcelain Enameling
D Dental Schools D Dental Clinics
D Dry Cleaning
□ Electrical Component
□ Manufacturing
□ Fertilizer Manufacturing
□ Film/ X-ra y Processing
D Electroplating
D Electroless Plating
□Anodizing D Coating (i.e. phosphating)
D Chemical Etching/Milling
D Printed Circuit Board D Manufacturing
0 Power Generation D Print Shop D Research and Development
D Rubber Manufacturing D Semiconductor Manufacturing
D Soap/Detergent Manufacturing D Waste Treatment/Storage
\.,£,□ I 'II b 7//""_7)2/ New Business? Yesr SIC Code(s) if known; ______ Date operation began w1 egin: __ ~,1--~~,~-· ~-_
Tenant Improvement? Yes~oO If yes, briefly describe improvement: ___________________ _
Description of operations generating wastewater (discharged to sewer, hauled orevaporated): _______ -r __ _
J, ')(/1'.{/'c (:'_ t&• 7<:'l),'<:,~ 0 Gt:;H::,~1 l,),1,;,k liar1viuJ,1",J,,r1i: tlK,_ ==~~=====±!.===========~======~====~
Estimated volume of industrial wastewater to be discharged (gal/ day) : _,,N_-__cl_' 11_,_ ________________ _
List hazardous wastes generated (type/volume): ___ _,)Jc.,_.:0:_:Nc._:___£ _______________________ _
Have you applied for a Wastewater Discharge Permit from the Encina Wastewater Authority? YesOoate:
Page 1 of 2
ENCINA WASTEWATER AUTHORITY
INDUSTRIAL WASTEWATER DISCHARGE PERMIT
SCREENING SURVEY
6200 Avenida Encinas, Carlsbad, CA 92011
Phone: 760-438-3941 Fax: 760-476-9852
SourceControl@encinajpa.com
The commercial enterprises listed below are a partial listing of businesses that are exempt from industrial wastewater discharge
permitting under normal operating conditions. They are exempt because (a) they discharge no process wastewater (i. e., they
only discharge sanitary wastewater with no pollutants exceeding any local limits ), and (b) they have no potential to negatively
impact the EWPCF or other wastewater treatment plants in the ESS. Any questions regarding exemptions should be referred
to EWA Source Control staff.
□ Automobile Detailer s
□ Barber/Beauty Shops
□ Business/Sales Offices
□ Cleaning Services
□ CarpeUUpholstery
□ Childcare Facilities
□ Churches
□ Community Centers
□ Consulting Services
□ Contractors
□ Counseling Services
□ Educational Services (no auto repair/film
□ Financial Institutions/Services
□ Fitness Centers
□ Gas Stations (no car wash/auto repair)
□ Grocery Stores (no film developing)
□ Residential based Businesses
developing)
D Hotels/ Motels (no laundry)
D Laundromats
D Libraries
D Medical Offices (no x-ray developing)
D Mortuaries
D Museums
D NailSalons
D Nursing Homes
D Office Buildings (no process fiow)
5 Optical Services D Pest Control Services (no pesticide repackaging for sale)
D Pet Boarding/Grooming Facilities
□ □ □ □
Postal Services (no car wash/auto repair)
Public Storage Facilities
Restaurants/Bars
Retail/Wholesale Stores (no autorepair/film
developing)
D Theaters (Movie/Live)
CERTIFICATION STATEMENT
1 certify that the information above is tn1e and correct to the best ofmy knowledge.
Print Name Lyn "' De( y / t;::ft Date:
C/1 r,::, 11v"/ TC,\, Facility Contact: ______ L _____ _
ENCINA WASTEWATER AUTHORITY
6200AVENIDA ENCINAS, CARLSBAD, CA Phone: 760-438-3941 Fax: 760-476-9852
SourceControl@encinaipa _com
Page 2 of 2
( City of
Carlsbad
CAP Building Plan
Template
B-55
Development Services
Building Division
1635 Faraday Avenue
760-602-2719
www.carlsbadca.gov
INSTRUCTIONS: The following certificate shall be included on the title sheet of all building plans:
CLIMATE ACTION PLAN (CAP) COMPLIANCE
The following demonstrates project compliance with the applicable Climate Action Pian ordinances of the Carlsbad Municipal Code and California
Green Building Standards Code (CALGreen), current version:
1. ENERGY EFFICIENCY APPLICABLE:
Complies with CMC 18.30.190
& 18.21.155
Existing Structure, year built: 2003
Prepared Energy Audit?
Energy Score: _____ _
Efficiency Measures included in scope:
YE@g)
Yes /No
Yes/No
2. PHOTOVOLTAIC SYSTEM APPLICABLE: YES@
Complies with CMC section 18.30.130 and 2019 California Energy
Code section 150.1(c)14 Yes /No
Required Provided
Size of PV system (kWdc):
Sizing PV by load calculations
tf by Load Calculations:
Total calculated electrical load:
80% of load:
Hardship Requested
Hardship Approved
Yes/No
Yes/No
Yes/No
3. ALTERNATIVE WATER HEATING SYSTEM APPLICABLE:@No
Complies with CMC sections 18.30.150
and 18.30.170? @No
Alternative Source:
(X Electric
11 Passive Solar
Hardship Requested
Hardship Approved
4. ELECTRIC VEHICLE (EV) CHARGING APPLICABLE:
Complies with CMC
section 18.21.140?
Panel Upgrade?
Yes@
Yes/No
YES@
Yes /No
Yes/No
Required Provided
Total EV Parking Spaces:
No. of EV Capable Spaces:
No. of EV Ready Spaces:
No. of EV Installed Spaces:
Hardship Requested
Hardship Approved
5. TRAFFIC DEMAND MANAGEMENT APPLICABLE:
Compliant?
TOM Report on file with city?
Yes/No
Yes/No
YES@
Yes/ no
Yes/ no
( City of
Carlsbad
PURPOSE
CLIMATE ACTION PLAN
CONSISTENCY CHECKLIST
B-50
Development Services
Building Division
1635 Faraday Avenue
(760) 602-2719
www.carlsbadca.gov
This checklist is intended to assist building permit applicants identify which Climate Action Plan (CAP) ordinance
requirements apply to their projects. The completed checklist must be included in the building permit application. It may be
necessary to supplement the completed checklist with supporting materials, calculations or certifications, to demonstrate
full compliance with CAP ordinance requirements. For example, projects that propose or require a performance approach
to comply with energy-related measures will need to attach to this checklist separate calculations and documentation as
specified by the ordinances.
NOTE: The following type of permits are not required to fill out this form
❖ Patio I ❖ Decks I ❖ PME (w/o panel upgrade) I ❖ Pool
~ If an item in the checklist is deemed to be not applicable to a project, or is less than the minimum required by ordinance,
an explanation must be provided to the satisfaction of the Building Official.
~ Details on CAP ordinance requirements are available on the city's website.
~ A CAP Building Plan template (form B-55) shall be added to the title page all building plans. This template shall be
completed to demonstrate project compliance with the CAP ordinances. Refer to the building application webpage and
download the latest form.
Project Name/Building
Permit No.:
Property Address/ APN:
Applicant Name/Co.:
Applicant Address:
Contact Phone:
JAND, Inc. WARBY PARKER BP No.:
Forum Carlsbad, 1923 Calle Barcelona, Space 1398
Lyn Davies / PPS
75-60TH ST SW WYOMING MI 49584
616-493-9326 Contact Email: Jynd@precisionpermits.com
Contact information of person completing this checklist (if different than above):
Name:
Company
name/address:
ALYSON PALMER Contact Phone:
630 9TH AVE NY NY 10036 Contact Email:
Applicant Signature: -"'-~_w_&_A_IVS_·~-~_3 __________ Date: 4.26.2
8-50 Page 1 of 6
212-807-1011
}
City 0f Carlsbad Climate Action Plan Consistency Checklist
Use the table below to determine which sections of the Ordinance Compliance checklist are applicable to your project.
For alterations and additions to existing buildings, attach Building Permit Valuation worksheet.
Building Permit Valuation (BPV) from worksheet:$ z ( 1°'-ooO
Construct1911_ Type
D Residential
□ New construction
□ Additions and alterations:
□ BPV < $60,000
□ BPV " $60,000
□ Electrical service panel upgrade only
□ BPV" $200,000
lxJ Nonresidential
□ New construction
ll!I Alterations:
~ BPV" $200,000 or additions " 1,000
square feet
□ BPV 2: $1,000,000
□ "2,000 sq. ft. new roof addition
Complete Sectlo!1(s) Notes:
A high-rise residential building is 4 or more stories, including a
Low-rise High-rise mixed-use building in which at least 20% of its conditioned floor
area is residential use
N/A N/A All residential additions and alterations
1A, 4A 4A 1-2 family dwellings and townhouses with attached garages
only
'Multi-family dwellings only where interior finishes are removed
1A, 4A' 1 B, 4A' and significant site work and upgrades to structural and
mechanical, electrical, and/or plumbing systems are proposed
1B, 2B, 3B, 4B and 5
1B, 5
1B, 2B, 5 Building alterations of" 75% existing gross floor area
2B, 5 1 B also applies if BPV" $200,000
>·•'~'.·-:._·::j •. '.·' ,_< >:,-·,·>•:··'.· -;.'~.t~; _"'·"· ,'. ' ·;-,·>:":: ·· -;i.·J,:·.s-, } i '":,·/ :.::::~:i '\',-~ '••· /, : ... ~·,-1.·-~ · ;.,. -: ,,; :1,i' •:'?;-; · •'-'<· ..• : ::/• ·>,., • _:t,' ·· .· ·
·•· ·~ •··1~f~~~l~~~~a;~*~~@~iJ~~.·~~~~1~~'~i~t&~<t~~~~~~~~
1. Energy Efficiency
Please refer to Cansbad Municipal Code (CMG) sections 18.21.155 and 18.30.190, and the California Green Building Standards Code (CAL Green) for
more information when completing this section.
A D Residential addition or alteration~ $60,000 building permit valuation.
See CMC section 18.30.190,
Year Built I Single-family Requirements
□ Before 1978 Select one:
□ Duct sealing □ Attic insulation □ Cool roof
□ 1978 and later Select one:
□ Lighting package □ Water heating Package
□ Between 1978 and 1991
□ 1992 and later
□ N/A _________ _
□ Exception: Home energy score~ 7
(attach certification)
Multi-family Requirements
□ Attic insulation
Select one:
□ Duct sealing □ Attic insulation □ Cool roof
Select one:
□ Lighting package □ Water heating package
B. IR] Nonresidential' new construction or alterations~ $200,000 building permit valuation,
or additions ~ 1,000 square feet. □ N/A
Updated 8/15/2019 2
OFFICE USE ONLY
i o: ndicate y circling the Item. whether your usrness Will use, process, or store any of the o lowing hazardous materials
appficant must contact the Fire Protection Agency with jurisdiction prior to plan submittal
Occupancy Rating: Facility's Square Footage (including proposed prOje<..'t):
1. Explosive or Blasting Agents 5. Organic Peroxides 9. Water Re.actives 13 Corrosives
2. Compressed Gases
3. Flammable/CombustibJe Uqu·1ds
6. Oxidizers 1 0 Cryogenics
I Pyrophorics 11 Hfgh!y Toxic or Toxic Materials
14 Other Health Hazards
15. None of These.
4. Flammable Solids 8. Unstable React1ves 12. Radio.actives
Questions is yes, applicant mus! contact the County of San Diego Hazar ous k aterials ivision, 5500 Overland Avenue,
Cal! (858} 505-6700 prior to the issuance of a building permit
FEES ARE REQUIRED PrQlect Comp{etion Date: Expected Date of Occupancy;
1.
2.
3
4
5.
6
7
8
YES NO (for new construction or remodeling pro}ects) 0 ri1, Is your business listed on the reverse side of this form? (Check au that apply).
0 &I WIU your buSiness dispose of Hazardous Substances or Medk:a! Waste in any amount? D (R Will your business store or handle H%1ardous Substances Ir quantities greater than or equal to tb gallons, 500
pounds and/or 200 cubic feet?
D I. Will your business store or handle carcinogens/reprOductive toxins in any quantity? 0 Will your business use an existing or install an underground storage tank?
D Will your business store or handle Regulated Substances (CalARP)? 0 fl Will your business use or install a Hazardous Waste Tank System (Title 22, Article 10)? 0 ,@ WiU YQUr business store petroleum in tanks or containers at your facility with a total facility storage capacity equar to
or greater !han 1,320 gallons? (California's Aboveground Petroleum Storage Act).
: If the answer to any of the
n Diego, CA 92123
0 CalARP Exempt
I
Date lmlials
0 CalARP Required
I
Initials
0 CalARP Cornplele
___ L .... --
oare lmhal$
PART Ill: SAN OfEGO COUNTY AIR POLLUTION CONTROL DISTRICT (APCO); The fallowing questions are inlended lo identify the majority of air pollurion
issues at the planning stage. Your project may require additional measures not identified by these questions. Some residential projects may be exempt from APCD
reqwrements. If yes is answered for either questions 1. 2 or 5 or for more comprehensive requirements, please contact APCO at :,.i.,c., ·,;,,:;L'.:_:;\C::::L ,-.
(858) 566-2650: or 10124 Old Grove Road. San Diego, CA 92131.
YOES NQ
1 lz9 Will the project disturb 100 square feet or more of existing b-uildmg materials?
2. 0 gJ Will any load supporting structural members be removed?
3 0 (3 {ANSWER ONLY IF QUESTION 1 or 2 JS YES) Has an asbestos survey been performed by an individual that has passed an EPA-approved
building inspecior course?
4_ 0 [& (ANSWER ONLY IF QUESTION 1 or 2 IS YES) Based on !he survey results. will the project disturb any asbesros containing material? ff yes. a
notification may be required at least 10 working days prior to commencing asbestos removal. Additionally, a notification may be required prior lo
the removat of a to.ad supporting structural member(s) regardless of the presence of asbestos.
5.
6 D
O Will the project or associated construction equipment emit air contaminants? See the reverse side of this forrn for typical equipment requiring an
APCD permit If yo<->, contact APCO prior to the issuanee of a building pertrut
{23. (ANSWER ONLY IF QUESTION 5 IS YES) WiU the project or associated construction eQuipment be located Within 1,000 teet of a school
,boundary?
i de. dare under pe. nalty 01:~ry that to_the best of my knowledge and be. /ieft e ~sponses,..-,.ade_herei·n·· are true and correct. V 2,..q_ 1 .. ? / _
/_:~ ~-~1 t=i~L....L .. --=.--C~ t.,1,--· ->~;,,~-\/ /__(_ .~ -,..,--,.,,,,,.. r _
Name ~Or Authorized Agent signature of Owner or Authorized A:a_ent ( { / Jr Date
FOR OFFICAJ. USE ONLY:
FIRE DEPARTMENT OCCUPANCY CLASSIFICATION-----------------~----------------
BY DATE I I -~-···--"--~-----· . -
EXEMPT OR NO FURTHER INl='ORMA1lON REQUIRED RELEASED l='OR 8/JILDING PERMIT BUT MOT FOR OCCUPANCY REl.EAsEO FOR OCCUPANCY
COUNTY HMO· APCO COUNTY-HMO APCO COUNTY •t·IMD APCD
I
''!,· ,·e-.-,.o< ';
•t OP/8/l'iJ[_Z;
::,·.' t11it,2i-,
) ., .. ;
·A stamp in this box~ exempts businesses from completing or updating a Ha.?ardous Materials Business Plan. Other permitting requrrements may still apply
HM.9171 (9118/ County of S-M Diego • DEH -Hazardous Mater'1a!s Division
{ City of
Carlsbad
CONSTRUCTION WASTE
MANAGEMENT PLAN
B-59
Building Division
1635 Faroday Avenue
760-602-2719
www.carlsbadca.gov
Many of the materials generated from your project can be recycled. You are required to list materials that will be
reused, recycled or disposed from your project. If you have questions about the recycling requirement or completing
this form, please contact Waste Management at (760) 929-9400, a certified C&D recycler, or the Carlsbad Building
Division at (760) 602-2700. Please note: Unless__youare self-hauling, Waste C\llanagement or approved haulers must be
used for all constructiqn projects with_in the <:ity of Carlsbad.
PAHT 1
Permit No.
Project Address
Applicant Name
Applicant Information
' Project Title t(/,An,:r-l"/42/c 'f:;,.J!.....-
tf;!. 7 C-/rt{£_ 8,,,rf/<. l {,, {o,,v .+-/S'J 5 APN
./4ok-1 t/(,l1/;,rt,,J :i-,rrf-O '~' [J [J
lost f,rst ,. ?2,:;77
70//P {tzt!PW,vf/4tt7 l:.c...;7 I {A·Gc<' ,;v4-//4 }~f' I{'.# Applicant Address
Phone
Applicant Mailing Address
(if different than project address)
Project Type
(check all thar apply}:
Brief Description
Project Size (700
{square footage)
Please check the appropriate box:
E-mail Address ~);u,.,,,J-5,nz. {i!_ Cei )< -..-1.l C-1-
lndus:rial □
C),:;/U
~non using WASTE MANAGEMENT roll-off bin(s) for all materials and will provide all receipts after construction.
DI plan on self-hauling to a certified recycling facility and will provide all receipts after construction.
D This is a proposed LEED certified project and I plan on separating materials on site in conjunction with WASTE
MANAGEMENT.
Acknowledgement: I certify under penalty of perjury under the laws of the State of California that the information
provided in and with this form pertains to construction and demolition debris generated only from the project listed
in PARl 1, that I have reviewed the accuracy of the mformat1on~and tha the information 1s true and correct to the
best of my knowledge and belief y" j
Print Name /,{hf/r/'-1 !kJ-_Signature t / Z-f-1-t--__ Date '6/ 1 0c Z/
Page 1 of 3 Rev ?.10.21