HomeMy WebLinkAbout1145 TAMARACK AVE; ; CBR2019-3546; PermitPrint Date: 02/05/2020
Job Address:
Permit Type:
Parcel No:
Valuation:
Occupancy Group:
# Dwelling Units:
Bedrooms:
Project Title:
1145 Tamarack Ave
BLDG-Residential
2062610700
$1,209.26
Residential Permit
Work Class: Alteration
Lot#:
Reference#:
Construction Type:
Bathrooms:
Orig. Plan Check#:
Plan Check#:
Description: RIGNEY: 26 SF REMODEL OF PANTRY TO HALF BATH
Applicant: Owner:
RIGNEY FARRELL AND JENNIFER
1145 Tamarack Ave
CARLSBAD,CA 92008
RIGNEY FARRELL AND JENNIFER
1145 Tamarack Ave
CARLSBAD,CA 92008
BUILDING PERMIT FEE ($501-$2000)
BUILDING PLAN CHECK FEE (BLDG)
ELECTRICAL BLDG RESIDENTIAL NEW/ADDITION/REMODEL
MECHANICAL BLDG RESIDENTIAL NEW/ADDITION/REMODEL
PLUMBING BLDG RESIDENTIAL NEW/ADDITION/REMODEL
SB1473 GREEN BUILDING STATE STANDARDS FEE
STRONG MOTION-RESIDENTIAL
Total Fees: $214.51 Total Payments To Date: $214.51
(city of
Carlsbad
Permit No: CBR2019-3546
Status:
Applied:
Issued:
Permit
Fina led:
Closed -Finaled
12/13/2019
12/13/2019
Inspector: MColl
Final
Inspection: 2/5/2020 10:35:04AM
Balance Due: $0.00
$59.42
$41.59
$30.00
$35.00
$47.00
$1.00
$0.50
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 \ 760-602-2700 I 760-602-8560 f I www.carlsbadca.gov
· (cicyof
Carlsbad
RESIDENTIAL
BUILDING PERMIT
APPLICATION
8-1
Plan Check
Est. Value
PC Deposit -----,---,=-----,--,_-
Date __,_l.:..,,.cl+/L>..l.).L...4-/L_ia,_f -
Job Address -1l.1c' '1jw·~·~i1tl~'Lt'.w!,c_~~~WlW~_JW."""~Suite: __ -___ APN: -----------
CT/Project#: Cfryv\,j)\)Q :Qtz._ Lot #:,___.,(,2'-'-_
Fire Sprinklers: yes@ Air Conditioning: yes/@
BRIEF DESCRIPTION OF WORK: ~l}&;:0:-T ~JJIL':\ ::fD
Electrical Panel Upgrade: yes(@
A:IPBk[ ('m)Q @\)tr
~u~ ~ v0+1rl
□ 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: J{c, SF of affected area Is the area a conversion or change of use ?G No
D Pool/Spa: rj' SF Additional Gas or Electrical Features? _ _,NQ-===-----------
D Solar: ?J( KW, ___ Modules, Mounted: Roof/ Ground, Tilt: Yes/ No, RMA: Yes/ No, Battery: Yes/ No
P~rade: Yes/ No
D Reroof: ___ -1---------=~-----------------------
D Plumbing/Mechanical/Electrical Only: _R.,.w .. · =··_.mu...iez..,..Tu.)=_,,,,,.(..,2'-------------------
□ Other: ____________________________________ _
APPLICANT (PRIMARY CONTACT)
Name: ~ f.Jb\\JCY
Address: I l':\:5 ~ f\J&
City: C fr/1...j ~ Sta~e: ell-Zip: 'W:6 b Is'
Phone:(1{p}i67 -,~;}..~
Ema ii: C kJ ; ~ c. G:ico,-,.d Cv l\ tt2(' • G:::D'.'::'-
DESIGN PROFESSIONAL
Name: _________________ _
Address: ________________ _
City: ________ State: ___ Zip: ___ _
Phone: _________________ _
Email: _________________ _
Architect State License: ___________ _
PROPERT~OWN~ER ~
Name: -~w.=..,..,,c>.<.~--'-""='-'--'-~l-,--,7""-------
Address: L\ frJJt_
city:~e,M~m-~_Zip, ™
Phone:~ ~1-"J lci2b
Email: r, 'j~ ec..0 rc:p<l('nooec < u::,(IA_
CONTRACTOR BUSINESS
Name: ___________________ _
Address: _________________ _
City: ________ State: ___ Zip: ______ _
Phone: ___________________ _
Email: ___________________ _
State License:. ______ Bus. License:. ______ _
(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 exempt 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 {$500}).
1635 Faraday Ave Carlsbad, CA 92008 Ph: 760-602-2719 Fax: 760-602-8558 Email: Building@carlsbadca.gov
B-1 Page 1 of 2 Rev. 06/18
( OPTION A): WORKERS'COMPENSATION DECLARATION:
I hearby affirm under penalty of perjury one of the following declarations:
D I have and will maintain a certificate of consent to self-insure for workers' compensation provided by Section 3700 of the Labor Code, for the performance of the
work which this permit is issued.
□ I have and will maintain worker's compensation, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation insurance carrier and policy number are: Insurance Company Name: ______________________ _
Policy No. ______________ Expiration Date: _________ _
jl$ 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 add it' the to the cost of compensation, damages as provided for in Section 3706 of the Labor Code,
interest and attorney's fees. / ~
CONTRACTOR SIGNATURE: -----'==-i~:_----JL_..,L _______ □AGENT DATE, ~Jjt i,3:f'
( 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).
0 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).
)!(1 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. l will provide some of the work, but hired) the following persons to provide the work indicated (include name/ address/ ph
OWNER SIGNATURE:
CONSTRUCTION LENDING AGENCY, IF ANY:
ruction lending agency for the performance of the work this permit is issued (Sec. 3097 (i) Civil Code).
Lender's Address: _____________________ _
ONLY COMPLETE THE FOLLOWING SECTION FOR NON-RESIDENTIAL BUILDING PERMITS ONLY:
ts 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? D Yes D 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? D Yes D 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 CITY OF CARLSBAD AGAINST ALL LIABILITIES, JUDGMENTS, COSTS AND EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE OF
THE GRANTING OF THIS 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 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 180 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 106.4.4 Uniform Building Code). t J
"'""'""".'"'" ,2---~ d; --,. • .,,, i.,,_,ap9..
1635 Faraday Ave Carlsbad, CA 92008 ~602-2719 Fax: 760-602-8558 Email: Building@carlsbadca.gov
B-1 Page 2 of 2 Rev. 06/18
Permit Type: BLDG-Residential Application Date: 12/13/2019 Owner:
Work Cla'ss: Alteration Issue Date: 12/13/2019 Subdivision:
Status: Closed -Finaled Expiration Date: 06/29/2020 Address:
IVR Number: 23677
Scheduled
Date
Actual ,
Start Date Inspection Type Inspection No.
12/24/2019 12/24/2019 BLDG-21 114800-2019
12/30/2019 12/30/2019
12/31/2019 12/31/2019
02/03/2020 02/03/2020
02/05/2020 02/05/2020
February 05, 2020
Underground/Unde
rfloor Plumbing
Checklist Item
BLDG-Building Deficiency
BLDG-24 114942-2019
Rough/To pout
Checklist Item
BLDG-Building Deficiency
BLDG-44 115036-2019
Rough/Ducts/Damp
ers
Checklist hem
BLDG-Building Deficiency
BLDG-17 Interior 115081-2019
Lath/Drywall
Checklist Item
BLDG-Building Deficiency
BLDG-Final 118176-2020
Inspection
Checklist Item
BLDG-Building Deficiency
BLDG-Final 118503-2020
Inspection
Checklist Item
BLOG-Building Deficiency
Inspection Status Primary Inspector
Passed Michael Collins
COMMENTS
Waste to POC at Powder Rm only.
Partial Pass Michael Collins
COMMENTS
1st stop, walls only
Passed Michael Collins
COMMENTS
Passed Michael Collins
COMMENTS
Failed Michael Collins
COMMENTS
No access, left card at entry door
Passed Chris Renfro
COMMENTS
RIGNEY FARRELL AND JENNIFER
CAMINO DEL SOL
1145 Ta ma rack Ave
Carlsbad, CA 92008-3418
Reinspection Complete
Complete
Passed
Yes
Reinspection Incomplete
Passed
Yes
Complete
Passed
Yes
Complete
Passed
Yes
Reinspection Complete
Passed
No
Complete
Passed
Yes
Page 1 of 1
(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.:
BP No.:
Applicant Address:
Contact Phone:
11 it;S-1'~ fu1f, OtU,,sOO{), CA qxpg
Contact information of person completing this checklist (if different than above):
Name:
Company
name/address:
Contact Phone:
Contact Email:
Applicant Signature: _Q_~~·~-~='l-i--?-~5:-----Date:_\_~~, l_?:}_.__R~--
B-50 Page 1 of 6 Revised 08/19
City of 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: $ ______ _
BI.Residential
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
□ New construction
jc( Additions and alterations:
□ BPV < $60,000 N/A N/A All residential additions and alterations
~ BPV;;, $60,000 1A, 4A 4A 1-2 family dwellings and townhouses with attached garages
□ Electrical service panel upgrade only only
'Multi-family dwellings only where interior finishes are removed
□ BPV;;, $200,000 1A, 4A' 1B,4A' and significant site work and upgrades to structural and
mechanical, electrical, and/or plumbing systems are proposed
D Nonresidential
□ New construction 1 B, 2B, 3B, 4B and 5
□ Alterations:
□ BPV;;, $200,000 or additions" 1,000 1B, 5 square feet
□ BPV" $1,000,000 1B, 2B, 5 Building alterations of;;, 75% existing gross floor area
□ "2,000 sq. ft. new roof addition 2B,5 1B also applies if BPV" $200,000
1. Energy Efficiency
Please refer to Carlsbad Municipal Code (CMC) sections 18.21.155 and 18.30.190, and the California Green Building Standards Code (CALGreen) for
more information when completing this section.
A '&!: Residential addition or alteration~ $60,000 building pennit valuation.
See CMC section 18.30.190.
D N/A _________ _
□ Exception: Home energy score" 7
(attach certification)
Year Built Single-family Requirements Multi-family Requirements
X( Before 1978 Select one:
D Duct sealinQ ~ttic insulation □ Cool roof D Attic insulation
D 1978 and later Select one:
□ Lighting package D Water heating Package
□ Between 1978 and 1991 Select one:
□ Duct sealinQ □ Attic insulation □ Cool roof
D 1992 and later Select one:
D Lighting package D Water heating package
B. D Nonresidential' new construction or alterations~ $200,000 building pennit valuation,
or additions ~ 1,000 square feel D N/A
Updated 8/15/2019 2
(
City of Carlsbad Climate Action Plan Consistency Checklist
See CMC 18.21.155 and CALGreen Appendix AS, Division A5.2-Energy Efficiency.
AS.203.1.1 Choose one: □ .1 Outdoor lighting □ .2 Warehouse dock seal doors
□ .3 Restaurant service water heating (comply ~th California Energy Code section 140.5, as amended) □ N/A _________ _
□ .4 Daylight design PAFs □ .5 Exhaust air heat recovery
A5.203.1.2.1
Choose one as applicable: □ .95 Energy budget □ .90 Energy budget □ N/A
A5.211.1"
□ On-site renewable energy □ NIA
A5.211.3"
□ Green power (if offered by local utility provider, 50% minimum renewable sources) □ NIA
AS.212.1
□ Elevators and escalators □ N/A
A5.213.1
□ Steel framing □ N/A
'Includes hotels/motels and high-rise residential buildings
"For alterations~ $1,000,000 BPV and affecting > 75% existing gross floor area, or alterations that add 2,000 square feet of new roof addition: comp~
with CMC 18.30.130 instead.
2. Photovoltaic Systems -1
A. D Residential new construction (for low-rise residential building pennit applications submitted after 1/1/20). Refer to 2019 California
Energy Code section 150.1(c)14 for requirements. Notes: 1) High-rise residential buildings are subjectto nonresidential photovoltaic
requirement(28 below) instead. 2) If project includes installation of an electric heat pump water heater pursuant to CMC 18.30.150(8)
(high-rise residential) or 18.30.170(8) (low-rise residential), increase system size by .3kWdc if PV offset option is selected.
Floor Plan ID (use additional CFA #d.u. Calculated kWdc'
sheets if necessary)
Total System Size:
kWdc = (CFAx.572) / 1,000 + (1.15 x #d.u.)
'Formula calculation where CFA = conditional floor area, #du= number of dwellings per plan type
If proposed system size is less than calculated size, please explain.
Exception
□
□
□
□
kWdc
8. D Nonresidential new construction or alterations ~$1,000,000 8PV and affecting ~75% existing floor area, or addition that increases roof
area by ~2,000 square feel Please refer to CMC section 18.30.130 when completing this section. Note: This section also applies to
high-rise residential and hotel/motel buildings.
Choose one of the following methods:
□ Gross Floor Area (GFA) Method
GFA:
□If< 10,000s.f. Enter: 5 kWdc
Min. System Size:
□ If~ 1 O,OOOs.f. calculate: 15 kWdc x (GFA/10,000) ..
kWdc
.. Round building size factor to nearest tenth, and round system size to nearest whole number.
□ Time-Dependent Valuation Method
Updated 8/15/20 I 9 3
City of Carlsbad Climate Action Plan Consistency Checklist
Annual TDV Energy use:"' ______ x .80= Min. system size: ____ _ kWdc
... Attach calculation documentation using modeling software approved by the California Energy Commission.
3. Water Healing
A D Residential and hotel/motel new construction
Please refer to CMC sections 18.30.150 and 18.30.170 when completing this section.
□ For systems serving individual dwelling units choose one:
□ Heat pump water heater AND Compact hot water distribution AND Drain water heat recovery (low-rise
residential only)
□ Heat pump water heater AND PV system .3 kWdc larger than required in CMG section 18.30.130 (high rise
residential hotel/motel) or CA Energy Code section 150.1 (c) 14 (low-rise residential)
□ Heat pump water heater meeting NEEA Advanced Water Heating Specification Tier 3 or higher
□ Solar water heating system that is either .60 solar savings fraction or 40 s.f. solar collectors
□ Exception:
□ For systems serving multiple dwelling units, install a central water-heating system with all of the following:
□ Gas or propane water heating system
□ Recirculation system per CMG 18.30.150(8) (high-rise residential, hotel/motel) or CMG 18.30.170(8) (low-
rise residential)
□ Solar water heating system that is either:
□ .20 solar savings fraction
□ .15 solar savings fraction, plus drain water heat recovery
□ Exception:
B. D Nonresidential new construction
Please refer to Carlsbad Ordinance CMC section 18.30.150 when completing this section.
□ Water heating system derives at least 40% of its energy from one of the following (attach documentation):
□ Solar-thermal □ Photovoltaics □ Recovered energy
□ Water heating system is (choose one):
□ Heat pump water heater
□ Electric resistance water heater(s)
□Solar water heating system with .40 solar savings fraction
□ Exception:
Updated 8/15/2019 4
City of Carlsbad Climate Action Plan Consistency Checklist
4. Electric Vehicle Charging
A D Residential New construction and major alterations*
Please refer to Carlsbad Ordinance CMC section 18.21.140 when completing this section.
□ One and two-family residential dwelling or townhouse with attached garage:
□ One EVSE Ready parking space required □ Exception :
□ Multi-family residential· □ Exception ·
Total Parking Spaces EVSESpaces
Proposed Capable Ready
Calculations: Total EVSE spaces= .10 x Total parking (rounded up to nearest whole number)
EVSE Installed= Total EVSE Spaces x .50 (rounded up to nearest whole number)
EVSE other= Total EVSE spaces-EVSE Installed
(EVSE other may be "Capable," "Ready" or "Installed.")
Installed Total
'Major alterations are: (1) for one and two-family dwellings and townhouses v,nth attached garages, alterations have a building permtt valuation~ $60,000
or include an electrical seivice panel upgrade; (2) for multifamily dwellings (three units or more v,nthout attached garages), alterations have a building permit
valuation~ $200,000, interior finishes are removed and significant site work and upgrades to structural and mechanical, electrical, and/or plumbing
systems are proposed.
B D Nonresidential new construction (includes hotels/motels) □ Exception ·
Total Parking Spaces EVSE Soaces
Proposed Caoable I Readv Installed Total
I
Calculation· Refer to the table below·
Total Number of Parkina Spaces provided Number of required EV Spaces Number of required EVSE Installed Spaces
□ 0-9 1 1
□ 10-25 2 1
□ 26-50 4 2
□ 51-75 6 3
□ 76-100 9 5
□ 101-150 12 6
□ 151-200 17 9
□ 201 and over 1 O percent of total 50 oercent of Reau ired EV Spaces
Updated 8/15/2019 5
City of Carlsbad Climate Action Plan Consistency Checklist
5. D Transportation Demand Management (TOM): Nonresidential ONLY
An approved Transportation Demand Management (TOM) Plan is required for all nonresidential projects that meet a threshold of employee-generated ADT.
City staff will use the table below based on your submitted plans to determine whether or nor your permit requires a TOM plan. IITDM is applicable to your
permit, staff will contact the applicant to develop a site-specific TOM plan based on the permit details.
Acknowledgment:
Employee ADT Estimation for Various Commercial Uses
Use
Office (all),
Restaurant
Retails
Industrial :✓/
Manufacturing
Warehousin
EmpADTfor
first 1,000 s.f.
20
11
8
4
4
4
EmpADTI
1000 s.f.,
13
11
4.5
3.5
3
1
1 Unless otherwise noted, rates estimated from /TE Trip
Generation Manual, 10'"Edition
2 For all office uses, use SAN DAG rate of 20 ADT/1,000 sf to
calculate employee ADT
3 Retail uses include shopping center, variety store, supermarket,
gyms, pharmacy, etc.
Other commercial uses may be subject to special
consideration
Sample calculations:
Office: 20,450 sf
1. 20,450 sf/ 1000 x 20 = 409 Employee ADT
Retail: 9,334 sf
1. First 1,000 sf= 8 ADT
2. 9,334 sf -1,000 sf= 8,334 sf
3. 8,334 sf/ 1,000 x 4.5 + 8 = 46 Em lo ee ADT
I acknowledge that the plans submitted may be subject to the City of Carlsbad's Transportation Demand Management Ordinance. I agree to be contacted should
my permit require a TD~d u rsta~ approved TOM plan is a condition of permit issuance. /
Applicant Signature ( ~ , Date \7-I \ ~ I Cf •
Person other than Applicant to be contacted for TDM compliance (if applicable):
Name(Printed): __________________ _ Phone Number: ------
Email Address: ___________________ _
Updated 8/15/20 I 9 6