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HomeMy WebLinkAbout1822 ASTON AVE; 100; CBC2021-0219; PermitPERMIT REPORT Commercial Permit Print Date: 03/07/2022 Job Address: 1822 ASTON AVE, # 100, CARLSBAD, CA 92008-7306 Permit Type: BLDG-Commercial Work Class: Tenant Improvement Parcel#: 2121202100 Track#: Valuation: $108,647.36 Lot#: Occupancy Group: B, Sl Project#: #of Dwelling Units: Plan#: Bedrooms: Bathrooms: Construction Type:VB Orig. Plan Check#: Plan Check#: Project Title: Description: HAYES: 2,336 SF T.I. Applicant: Property Owner: DP DESIGN INC JESUS GOMEZ BLACKMORE COLLEGE CORNER PARTNERS PO BOX 1810 3900 5TH AVE, # 290 RANCHO SANTA FE, CA 92067 SAN DIEGO, CA 92103-3121 (619) 299-0011 FEE STRONG MOTION -COMMERCIAL (SMIP) BUILDING PERMIT FEE {$2000+) ELECTRICAL BLDG COMMERCIAL NEW/ADDITION/REMODEL MECHANICAL BLDG COMMERCIAL NEW/ADDITION/REMODEL SB1473 -GREEN BUILDING STATE STANDARDS FEE BUILDING PLAN CHECK FEE {BLDG) FIRES Occupancies< 50,000sq. ft. Tl FIRE Plan Resub (3rd&Subsequent Submittal/hr) Total Fees: $1,874.93 Total Payments To Date: $1,874.93 (city of Carlsbad Permit No: CBC2021-0219 Status: Closed -Finaled Applied: 06/17/2021 Issued: 09/28/2021 Fina led Close Out: 03/07/2022 In spector: Final Inspection: Balance Due: TKers 09/29/2021 AMOUNT $30.42 $657.95 $89.00 $55.00 $5.00 $460.56 $373.00 $204.00 $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 ( City of Carlsbad COMMERCIAL BUILDING PERMIT APPLICATION 8-2 Plan Check cec,;;i{j ~ I -6:;J !Ct Est. Value tf//1~,' ~Y J ~{,., PC De posit Date {., / ) J f ;),f Suite: 100 APN: 212-120-21-00 ·----Job Address 1822 ASTON AVE CARLSBAD CA 92008 Tenant Name: HAYES ----------------Lot#: Vear Built: ____ _ Occupancy:_b ___ _ Construction Type· TYPE V -N Fire Sprinklers:'ie? 9 A/C:g;J 9 BRIEF DESCRIPTION OF WORK: two new rooms 2K sf 0 Addition/New: ___________ New SF and Use, ___________ New SF and Use, ___ Deck SF, Patio Cover SF (not including flatwork) __xj Tenant Improvement: ,?,, .3 :i(c SF, _____ SF, Existing Use ______ Proposed Use ______ _ Existing Use Proposed Use ______ _ O Pool/Spa: _____ SF Additional Gas or Elect rical Features? ___________ _ DD DD DD D Solar: ___ KW, ___ Modules, ___ Mounted, Tilt: Yes/ No, RMA: Yes/ No, Panel Upgrade: Yes/ No D Plumbing/Mechanical/Electrical Only: -------------------------- □ Other: This permit is to be issued in the name of the Property Owner as Owner-Builder, licensed contractor or Authorized Agent of the owner or contractor. The person listed as the Applicant below will be the main point of contact throughout the permit process. PROPERTY OWNER /',.,. ~ ,AP~LICANT J7(' PROPERTY OWNERS AUTHORIZED AGENT APPLICANT 0 Name: 0\ae,¥yvtqe VV~_ l,&'n.£< f-ti,(~: _____________ _ Address: 1811 Aston Avenue uite 100 Address: City: Carlsbad Phone: 760.804.9600 State:_c_A __ Zip:92008 Email: colleen@theblackmorecompany.com DESIGN PROFESSIONAL APPLI CANT 0 Name: Donald Pitman Design, Inc. Address: 3900 5th AVE Suite 290 City: San Diego State:_C_A __ Zip: 92103 Phone: 619-299-001 1 ext 204 Email: jesus@dpdesigninc.com Architect State License: __________ _ -------------------City:. __________ .State: ___ Zip: ____ _ Phone: __________________ _ Email: colleen@theblackmorecompany.com CONTRACTOR BUSINESS APPLICANT 0 Name: ___________________ _ Address:. __________________ _ City: ________ St ate:. ___ Zip:. _____ _ Phone: __________________ _ Email: __________________ _ State License: ______ Bus. License:. ______ _ 1635 Faraday Ave Carlsbad, CA 92008 B-2 Ph: 760-602-2719 Fax: 760-602-8558 Email: Builcling@carlsbadca .gov Rev. 08/20 Page 1 of 2 IDENTIFY WHO WILL PERFORM THE WORI< BY COMPLETING (OPTION A) OR (OPTION B) BELOW: (OPTION A): LICENSED CONTRACTOR DECLARATION: I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000} of Division 3 of the Business and Professions Code, one/ my license is in full force and effect. I also 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. Polley No. ________________________ _ DI 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: ____________________ _ D Certificate of Exemption: I certify that In the performance of the work for which this permit is issued, I sh~II not employ any person In any manner so as to become 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. CONSTRUCTION LENDING AGENCY, IF ANY: I hereby affirm that there 1s 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: ____________________ _ CONTRACTOR PRINT: _________ _ SIGN: _________ DATE: (OPTION B): OWNER-BUILDER DECLARATION: I hereby affirm that I am exempt from Contractor's License Low for the following reason: DI, 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). 'C71'1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The ft' 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). DI am exempt under Business and Professions Code Division 3, Chapter 9, Article 3 for this reason: D "Owner Builder acknowledgement and verification form" has been filled out, signed ancl att~ched to this application. Proof of identification attached. D Owners "Authorized Agent Form" has been filled out, signed and attached to this application giving the agelll outhortty to obtain the permit on the owner' behalf Proof of Identification attached. By my slgn~ture below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior to completion of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner-builder If it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable low, Section 7044 of the Business an(\~ernons Code, is avail le pon req est when this application Is :::e;;r:t~:~;:awin eb si eeZviwMnfo.co.;colow.html LJ)~J;\ DATE:--------- APPLICANT CERTIFICATION: SIGNATURE REQU IRED AT TH E TIME OF SUBMITTAL By my signature below, I certify that: I am the property owner or State of California licensed Contractor or authorized to act on the property owner or contractor's behalf I certify that I have read the applicatlon and state that the above information is correct and that the information on the plans is accurate. I agree ta comply with all City ordinances and Srote lows relating to building construction. I hereby authorize representative of the City of Carlsbad ta 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 construct/on of structures over 3 stories in height. ~ APPLICANT PRINT, Co l\evVI IV'\ © 11,Ut,p\,~N, (),o\Ul_,v.t_M f6lti DATE, 'B 1z-2c1 1635 Faraday Ave Carlsbad, CA 92008 Ph: 760-602-2719 Fax: 760-602-8558 Email: Building@ca rlsbadca.gov B-2 Page 2 of 2 Rev. 08/20 (_ Cicyof Carlsbad OWNER-BUILDER ACKNOWLEDGEMENT FORM B-61 Development Services Building Division 1635 Faraday Avenue 760-602-2719 www.carlsbadca.gov OWNER-BUILDER ACKNOWLEDGM~NT FORM Pursuant to State of Collfornla Health and Safety Code Section 1.9825-1.9829 To: Property Owner An application for construction permit(s) has been submitted in your name listing you as the owner-builder of the property located at: Site Address l0U /16foy) Ave Cad-6 baJ The City of Carlsbad ("City") Is providing you with this Owner-Builder Acknowledgment and Verification form to inform you of the responsibilities and the possible risks associated with typical construction activities issued in your name as the Owner-Builder. The City will not issue a construction permit untir you have read and initialed your understanding of each provision in the Property Owner Acknowledgment section below and sign the form. An agent of the owner cannot execute this notice unless you, the property owner, complete the Owner's Authorized Agent form and it Is accepted by the City of Carlsbad. INSTRUCTIONS: Please read and initial each statement below to acknowledge your understanding and verification of this Information by signature at the bottom of the form. These are very important construction related acknowledgments designed to inform the property owner of his/her obligations related to the requested permit activities. t. ~I understand a frequent practice of unlicensed contractors ls to have the property owner obtain an "Ownel' Builder" building permit that erroneously Implies that the property owner Is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any Injuries sustained by an unlicensed contractor and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my Insurance coverage for Injuries to workers on my property. II. ~I understand building permits are not required to be signed by property owners unless they are responsible ~r}Ce construction and are not hiring a licensed contractor to assume this responsibility. Ill. ~I understand as an "Owner-BuilderH I am the responsible party of record on the permit. I understand that 1 may protect myself from potential financial risk by hiring a licensed contractor and having the permit filed In his ~~1Jr name instead of my own. IV. ~I understand contractors are required by law to be licensed and bonded in California and to list their license ~u,_m~rs on permits and contracts. V. (All-f understand if I employ or otherwise engage any persons, other than California licensed contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. 1 REV.08/20 (._ Cifyof Carlstiad OWNERS AUTHORIZED AGENT FORM B-62 Development Services Building Division . 1635 Faraday Avenue 760-602-2719 www.carlsbadca.gov OWNER'S AUTI-IORIZED AGENT FORM Only a property owner, contractor or their authorized agent moy submit plans and applications for building permits. To authorize a third-party agent to sign for a building permit, the owner's third party agent must bring this signed form, which identifies the agent and the owner who s/he is representing, and for what Jobs s/he may obtain permits. The form must be completed in its entirety to be accepted by the City for each separate permit application. Note: The following Owners Authorized Agent form is required to be completed by the property owner only when designating an agent to apply for a construction permit on his/her behalf. AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Property Owner Acknowledgement, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work): (g'\\J&t Wb.St: tv t-~W Vt>1)rY\..> Project Location or Address: _lLM~'-'-1....,./l;......:....;As=-tLYJ~..:.,_;,_(\vt......_..__C.;....,,tl{....:.....;;(/2_b--'-'~-d ____ _ Name of Authorized Agent: _ __.Ql""-""-'U ____ -=-----=G~l..;.ow __ M ________ Tel No. 1tA) 4134o)f Address of Authorized Agent:__.l.>e..B..;..&tl ____ a.;a.Ms'-'-w;;....v\--'r-"~-w--=--__ 8-t,i_~l o_z _ _,,, _____ _ CartA?etJ CA '1 wo~ I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. ~}irlft~ Property Owner's Signature: ~-l3·1A Date: 1 Owner-Builder Acknowledgement Continued VI. ~I understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these ;!:'R1ay subject me to serious financial risk. VII.~ I understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work ls performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of ..... ~~:t!'ork is performed under contract with a licensed general building contractor. VIII.~ I understand as an Owner-Builder if I sell the property for which this permit Is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) which result from any latent ~~ction defects in the workmanship or materials. IX. ~ I understand I may obtain more Information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more Information n,~t licensed contractors. X. \]4_~_1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally and a'sic~ res onsib~pos construction activity at the following address: XI. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide "'~l'ljl applicable laws and requirements that govern Owner-Builders as well as employers. XICf{~ __ I agree to notify the Issuer of this form Immediately of any additions, deletions, or changes to any of the Information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractor's State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It ls also important for you to understand that if an unlicensed Contractor or employee of that individual or firm Is Injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner- Builder and wish to hire contractors, you will be responsible for verifying whether or not those contractors are properly licensed and the status of their workers' compensation coverage. Before a bulfding permit con be issued, this form must be completed, signed by the property owner and returned to the City of Carlsbad Building Division. I declare under penalty of perjury thot I have read and understand oil of the Information provided on thlS form and that my responses, Including my authority to sign this form, Is true and correct. I om aware that I hove the option to consult with legal counsel prior to signing this form, and I have etcher (J.} consulted with legal counsel pr/a, to signing this form or (2) hove waived this right in t/gnlng this form withDut the advice of leaol r,ounsel. QdleeAA ~\ ~~ Property Owner Name (PRINT) ftl laVfVYW Cd.Ii, f lorYIR-< 2 REV.08/20 PERMIT INSPECTION HISTORY for (CBC2021-0219) Permit Type: BLDG-Commercial Application Date: 06/17/2021 Owner: BLACKMORE COLLEGE CORNER PARTNERS Work Class: Tenant Improvement Issue Date: 09/28/2021 Subdivision: CARLSBAD TCT#85-24 UNIT#04 Status: Closed -Finaled Expiration Date: 09/28/2023 Address: 1822 ASTON AVE, # 100 IVR Number: 34013 CARLSBAD, CA 92008-7306 Scheduled Actual Inspection Type Inspection No. Inspection Primary Inspector Reinspection Inspection Date Start Date Status Monday, March 7, 2022 Page 2 of 2 Building Permit Inspection History Finaled Ccityof Carlsbad PERMIT INSPECTION HISTORY for (CBC2021-0219) Permit Type: BLDG-Commercial Application Date: 06/17/2021 Owner: BLACKMORE COLLEGE CORNER PARTNERS Work Class: Tenant Improvement Issue Date: 09/28/2021 Subdivision: CARLSBAD TCT#85-24 UNIT#04 Status: Closed -Finaled Expiration Date: 09/28/2023 Address: 1822 ASTON AVE, # 100 IVR Number: 34013 CARLSBAD, CA 92008-7306 Scheduled Actual Inspection Type Inspection No. Inspection Primary Inspector Reinspection Inspection Date Start Date Status 08/17/2021 08/17/2021 BLDG-84 Rough 164310-2021 Passed Tim Kersch Complete Combo(14,24,34,44) Checklist Item COMMENTS Passed BLDG-Building Deficiency Yes BLDG-14 Yes Frame-Steel-Bolting-Welding (Decks) BLDG-24 Rough-Topout Yes BLDG-34 Rough Electrical Yes BLDG-44 Yes Rough-Ducts-Dampers 08/19/2021 08/19/2021 BLDG-16 Insulation 164515-2021 Passed Tim Kersch Complete Checklist Item COMMENTS Passed BLDG-Building Deficiency Yes 08/24/2021 08/24/2021 BLDG-17 Interior 164875-2021 Passed Tim Kersch Complete Lath/Drywall Checklist Item COMMENTS Passed BLDG-Building Deficiency Yes 09/15/2021 09/15/2021 BLDG-85 T-Bar, Ceiling 166462-2021 Passed Tim Kersch Complete Grids, Overhead Checklist Item COMMENTS Passed BLDG-Building Deficiency Yes BLDG-14 Yes Frame-Steel-Bolting-Welding (Decks) BLDG-24 Rough-Topout Yes BLDG-34 Rough Electrical Yes BLDG-44 Yes Rough-Ducts-Dampers 09/29/2021 09/29/2021 BLDG-Final Inspection 167512-2021 Passed Tim Kersch Complete Checklist Item COMMENTS Passed BLDG-Building Deficiency Yes BLDG-Plumbing Final Yes BLDG-Mechanical Final Yes BLDG-Structural Final Yes BLDG-Electrical Final Yes Monday, March 7, 2022 Page 1 of 2 SAN DIEGO REGIONAL HAZARDOUS MATERIALS QUESTIONNAIRE OFFICE USE ONLY RECORD ID # _________________ _ PLAN CHECK# ________________ _ BP DATE Business Name hayes Business Contact Telephone# Project Address (include suite) City Carlsbad State CA Zip Code APN# 212-120-21-00 Mailing Address (include suite) City State Zip Code Plan File# Project Contact Applicant E-mail Telephone# The following questions represent the facility's activities, NOT the specific project description. PART I: FIRE DEPARTMENT -HAZARDOUS MATERIALS DIVISION: OCCUPANCY CLASSIFICATION: (not required for projects within the City of San Diego}: Indicate by circling the item, whether your business will use, process, or store any of the following hazardous materials. If any of the items are circled, applicant must contact the Fire Protection Agency with jurisdiction prior to plan submittal. Occupancy Rating: Facility's Square Footage (including proposed project): 1. Explosive or Blasting Agents 5. Organic Peroxides 9. Water Reactives 13. Corrosives 2. Compressed Gases 6. Oxidizers 10. Cryogenics 14. Other Health Hazards 3. Flammable/Combustible Liquids 7. Pyrophorics 11. Highly Toxic or Toxic Materials 15. None of These. 4. Flammable Solids 8. Unstable Reactives 12. Radioactives PART II: SAN DIEGO COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH -HAZARDOUS MATERIALS DIVISION (HMO): If the answer to any of the questions is yes, applicant must contact the County of San Diego Hazardous Materials Division, 5500 Overland Avenue, Suite 170, San Diego, CA 92123. Call (858) 505-6700 prior to the issuance of a building permit. FEES ARE REQUIRED Project Completion Date: Expected Date of Occupancy: 0 CalARP Exempt I 1. 2. 3. 4. 5. 6. 7. 8. YES NO (for new construction or remodeling projects) Is your business listed on the reverse side of this form? (check all that apply). B El_•_-_· I!] Will your business dispose of Hazardous Substances or Medical Waste in any amount? □ □ Will your business store or handle Hazardous Substances in quantities greater than or equal to 55 gallons, 500 pounds and/or 200 cubic feet? B El □ El Will your business store or handle carcinogens/reproductive toxins in any quantity? El Will your business use an existing or install an underground storage tank? El Will your business store or handle Regulated Substances (CalARP)? El Will your business use or install a Hazardous Waste Tank System (Title 22, Article 10)? El Will your business store petroleum in tanks or containers at your facility with a total facility storage capacity equal to or greater than 1,320 gallons? (California's Aboveground Petroleum Storage Act). Date Initials 0 CalARP Required I Date Initials 0 CalARP Complete 6/14121 / Date Initials PART Ill: SAN DIEGO COUNTY AIR POLLUTION CONTROL DISTRICT (APCD): The following questions are intended to identify the majority of air pollution issues at the planning stage. Your project may require additional measures not identified by these questions. Some residential projects may be exempt from APCD requirements. If yes is answered for either questions 1, 2 or 5 or for more comprehensive requirements, please contact APCD at apcdcomp@sdcounty.ca.gov; (858) 586-2650; or 10124 Old Grove Road, San Diego, CA 92131. 1. 2. 3. 4. 5. 6. YES NO 1:1 I!) □ IE □ □ □ l!I I!) □ Will the project disturb 100 square feet or more of existing building materials? Will any load supporting structural members be removed? (ANSWER ONLY IF QUESTION 1 or 2 IS YES) Has an asbestos survey been performed by an individual that has passed an EPA-approved building inspector course? (ANSWER ONLY IF QUESTION 1 or 2 IS YES) Based on the survey results, will the project disturb any asbestos containing material? If yes, a notification may be required at least 1 O working days prior to commencing asbestos removal. Additionally, a notification may be required prior to the removal of a load supporting structural member(s) regardless of the presence of asbestos. Will the project or associated construction equipment emit air contaminants? See the reverse side of this form for typical equipment requiring an APCD permit. If yes, contact APCD prior to the issuance of a building permit. (ANSWER ONLY IF QUESTION 5 IS YES) Will the project or associated construction equipment be located within 1,000 feet of a school bounda ? Briefly describe business activities: Briefly describe proposed project: I declare under penalty of perjury that to the best of my knowledge and belief t e responses made herein are true and correct. I I Name of Owner or Authorized Agent Signature of Owner or Authorized Agent Date FOR OFFICAL USE ONLY: FIRE DEPARTMENT OCCUPANCY CLASSIFICATION: ________________________________ _ BY: ____________________________ _ DATE: __ _,_/ __ ---'-/ __ _ EXEMPT OR NO FURTHER INFORMATION REQUIRED RELEASED FOR BUILDING PERMIT BUT NOT FOR OCCUPANCY RELEASED FOR OCCUPANCY COUNTY-HMO• APCD COUNTY-HMO APCD COUNTY-HMO APCD .. "A stamp in this box only exempts businesses from completing or updating a Hazardous Materials Business Plan. Other permitting requirements may still apply HM-9171 (9/18) County of San Diego -DEH -Hazardous Materials Division □ □ □ □ □ □ □ □ □ □ ENCINA WASTEWATER AUTHORITY INDUSTRIAL WASTEWATER DISCHARGE PERMIT SCREENING SURVEY 6200 Avenida Encinas, Carlsbad, CA 92011 Phone: 760-438-3941 Fax: 760-476-9852 SourceControl@enci naj pa.com Date: 6/14/21 Business Name: hayes --------------------- Street Address: 1822 aston ave carlsbad ca 92008 Email Address: jesus@dpdesigninc.com PLEASE CHECK HERE IF YOUR BUSINESS IS EXEMPT : (ON REVERSE SIDE CHECK TYPE OF BUSINESS) □ Check all below that are present at your facility: Acid Cleaning D Food Processing D Metal Powders Forming Assembly D Glass Manufacturing D Nutritional SupplemenWitamin Automotive Repair D Industrial Laundry D Manufacturing Battery Manufacturing D Ink Manufacturing D Painting/Finishing Biofuel Manufacturing D Laboratory D Paint Manufacturing Biotech Laboratory D Machining/Milling D Personal Care Products Bulk Chemical Storage D Membrane manufacturing D Manufacturing Car Wash D (i.e. waterfilter membranes) D Pesticide Manufacturing/ Packaging Chemical Manufacturing D Metal Casting/Forming D Pharmaceutical Manufacturing Chemical Purification D Metal Fabrication D (including precursors) D Dental Offices D Metal Finishing D Porcelain Enameling D Dental Schools D Electroplating D Power Generation D Dental Clinics D Electroless Plating D Print Shop D Dry Cleaning D Anodizing D Research and Development D Electrical Component D Coating (i.e. phosphating) D Rubber Manufacturing □ Manufacturing D Chemical Etching/Milling D Semiconductor Manufacturing □ Fertilizer Manufacturing D Printed Circuit Board D Soap/Detergent Manufacturing □ Film/ X-ray Processing D Manufacturing D Waste TreatmenUStorage New Business? YesONo[:I SIC Code(s) if known: Date operation began/will begin: ______ _ Tenant Improvement? Yes E]NoO If yes, briefly describe improvement: 2k of office/warehouse space on existing warehouse Description of operations generating wastewater (discharged to sewer, hauled or evaporated): __________ _ Estimated volume of industrial wastewater to be discharged (gal/ day) : _____________________ _ List hazardous wastes generated (type/volume): ____________________________ _ Have you applied for a Wastewater Discharge Permit from the Encina Wastewater Authority? YesODate: ___ No□ 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 □ Carpet/Upholstery □ 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 Nail Salons D Nursing Homes D Office Buildings (no process flow) D Optical Services D Pest Control Services (no pesticide repackaging for sale) D Pet Boarding/Grooming Facilities D Postal Services (no car wash/auto repair) D Public Storage Facilities D Restaurants/Bars D Retail/Wholesale Stores (no autorepair/film developing) D Theaters (Movie/Live) CERTIFICATION STATEMENT I certify that the information above is true and correct to the best ofmy knowledge. Digitally signed by Jesus Jesus Gomez g~:•~02, 00141156,43 Signature: -oToo· Print Name: Jesus Gomez 6/14/21 Date: ____ _ Colleen Blackmore Facility Contact: __________ _ Title: Owner ENCINA WASTEWATER AUTHORITY 6200AVENIDA ENCINAS, CARLSBAD, CA Phone: 760-438-3941 Fax: 760-476-9852 SourceControl@encinajpa.com Page 2 of 2