HomeMy WebLinkAbout2170 TWAIN AVE; ; CBR2020-0520; PermitBuilding Permit Finaled
Residential Permit
Print Date: 08/01/2023
Job Address:
Permit Type:
Parcel#:
Valuation:
Occupancy Group:
#of Dwelling Units:
Bedrooms:
Bathrooms:
Occupant Load:
Code Edition:
Sprinkled:
Project Title:
2170 TWAIN AVE,
BLDG-Residential
2081802700
$48,597.43
CARLSBAD, CA 92008-4617
Work Class:
Track#:
Lot#:
Project#:
Plan#:
Construction Type:
Orig. Plan Check#:
Plan Check#:
Description: HORN: 347 SF POOL & SPA (NO RETAINING WALLS)
FEE
BUILDING PERMIT FEE ($2000+)
BUILDING PLAN CHECK FEE (BLDG)
Property Owner:
ROBERT HOM
2170 TWAIN AVE
CARLSBAD, CA 92008-4617
(714 I 403-5406
ELECTRICAL BLDG RESIDENTIAL NEW/ADDITION/REMODEL
PLUMBING BLDG RESIDENTIAL NEW/ADDITION/REMODEL
SB1473 GREEN BUILDING STATE STANDARDS FEE
STRONG MOTION-RESIDENTIAL
SWPPP INSPECTION FEE TIER 1-Medium BLDG
SWPPP PLAN REVIEW FEE TIER 1-MEDIUM
Pool
Total Fees: $1,091.64 Total Payments To Date: $1,091.64
(city of
Carlsbad
Permit No:
Status:
CBR2020-0520
Closed -Finaled
Applied: 03/03/2020
Issued: 06/02/2020
Finaled Close Out: 08/01/2023
Final Inspection: 07/27/2023
INSPECTOR: Dreibelbis, Peter
Renfro, Chris
Burnette, Paul
CoApplicant:
BP WATER CONCEPTS INC
BEN BOTELLO
1119 5 MISSION RD, # 196
FALLBROOK, CA 92028-3298
(858) 243-3803
Balance Due:
AMOUNT
$399.60
$279.72
$41.00
$62.00
$2.00
$6.32
$246.00
$55.00
$0.00
Please take NOTICE that approval of your project includes the "Imposition" of fees, dedications, reservations, or other exactions hereafter
collectively referred to as "fees/exaction." You have 90 days from the date this permit was issued to protest imposition of these
fees/exactions. If you protest them, you must follow the protest procedures set forth in Government Code Section 66020(a), and file the
protest and any other required information with the City Manager for processing in accordance with Carlsbad Municipal Code Section
3.32.030. Failure to timely follow that procedure will bar any subsequent legal action to attack, review, set aside, void, or annul their
imposition.
You are hereby FURTHER NOTIFIED that your right to protest the specified fees/exactions DOES NOT APPLY to water and sewer connection
fees and capacity changes, nor planning, zoning, grading or other similar application processing or service fees in connection with this
project. NOR DOES IT APPLY to any fees/exactions of which you have previously been given a NOTICE similar to this, or as to which the
statute of limitation has previously otherwise expired.
Building Division Page 1 of 1
1635 Faraday Avenue, Carlsbad CA 92008-7314 I 442-339-2719 I 760-602-8560 f I www.carlsbadca.gov
(cicyof
Carlsbad
RESIDENTIAL
BUILDING PERMIT
APPLICATION
B-1
Plan Check C/3h9-D)C:-6'5«!!•
Est. Value ~ 2, Y1 ':f '-1$ ' PC Deposit --,-~-----
Date "7o/3k:J.ta-+"'-
JobAddress d\lO Tw<~•/1 Pv--Suite: APN: 2.:.E,--IW -1-7-W -----
CT/Project#:, _________________ Lot#: ___ _
Fire Sprinklers: yes/ no Air Conditioning: yes/ no I Electrical Panel Upgrade: yes/ no
BRIEF DESCRIPTION OF WORK: J~~t)l,~\~;_'.S:?jf'~C.:'_, _J~l..(~•~j5~1~-¥\-~' :__,~~-==I El
1
~1§:§§1 ,~-~t~!~t~• ~J~c;l~1=3(i:1 ic~eJ\1---
0 Addition/New: _____ Living SF, ____ Deck SF, ____ Patio SF, ____ Garage SF
Is this to create an Accessory Dwelling Unit? Yes/ No New Fireplace? Yes/ No, if yes how many? __
D Remodel: _____ SF of affected area Is the area a conversion or change of use? Yes/ No
~ool/Spa: 3'-\::=J: SF Additional Gas or Electrical Features? ____________ _
□ Solar: ___ KW, ___ Modules, Mounted: Roof/ Ground, Tilt: Yes/ No, RMA: Yes/ No, Battery: Yes/ No
Panel Upgrade: Yes/ No
D Reroof: _____________________________________ _
lJ Plumbing/Mechanical/Electrical Only: ________________________ _
D Other: ____________________________________ _
APPLICANT {PRIMARY CONTACT)
Name: Cc.£r,( JOf'\C)
Address: qqJt Cg,~ I M1n Pt{ <¥7 ES'
City: 20 State:l~ Zip: 9:;i1;}.7
Phone: ktt:/ -1L(]. -5'ioB
Email: CJ•rhe j'~.r(!,,j O kct"'lL I l -c:~, '
DESIGN PROFESSIONAL
Name: _________________ _
Address: ________________ _
City: ________ State:. ___ Zip: ___ _
PROPERTY OWNER
Name: 9'y ~r..-,
Address: ?--1,0 Di-?<'"'~
City: C<'-f'l,sl,".{ State: CC\ Zip: "I Zj)'.) 0
Phone: 11':1-4o3-S40b
Email: ____________________ _
CONTRACTOR BUSINESS
Name: BP l.)C.\'C/ D-/\~P h Ji:,.c -
Address: ln'-i '5 MtJl/l.l"I P-d.,,,lqb
City: fill br,.;~,k,, State: C2\ Zip: qy, 2,[J
Phone:_______________ Phone: ~ni 1-':()-3S;1113
Email:--------------Email: 0\>IJc,\-el'Ci~cP l1(?,, -:,Iv\,,, I -~
Architect State License:____________ State License: ~ Bus. License:
{Sec, 7031 5 Busmess and Professmns Code Any C,ty or County wh<eh requ,res a perm,t to construct,£2~1Jemol,s£~,(,,n~~rdu-?e~;Po(,, -;:).,ej /[i'
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 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars {$SOD}).
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:
□ 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.
0 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 ls unlawful, and shall subject an employer to
criminal penalties and civil fines up to $100,0 in addition the to the cost of compensation, damages as provided for in Section 3706 of the Labor Code,
interest and attorney's fees.
CONTRACTOR SIGNATURE:
( OPTION B ): OWNER-BUILDER DECLARATION:
I hereby affirm that I am exempt from Contractor's License Low 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).
D I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The
Contractor's 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).
0 I am exempt under Section ________ Business and Professions Code for this reason:
1. I personally plan to provide the major labor and materials for construction of the proposed property improvement. □ Yes □ No
2. I (have/ have not) signed an application for a building permit for the proposed work.
3. I have contracted with the following person (firm) to provide the proposed construction (include name address/ phone/ contractors' license number):
4. I plan to provide portions of the work, but I have hired the following person to coordinate, supervise and provide the major work {include name/ address/ phone/
contractors' license number):
5. I will provide some of the work, but I have contracted (hired) the following persons to provide the work indicated (include name/ address/ phone/ type of work):
OWNER SIGNATURE: LJAGENT DATE: _____ _ ---------------------------
CONSTRUCTION LENDING AGENCY, IF ANY:
I hereby affirm that there is a construction lending agency for the performance of the work this permit is issued (Sec. 3097 (i) Civil Code).
Lender's Name: _____________________ _ Lender's Address: _____________________ _
ONLY COMPLETE THE FOLLOWING SECTION FOR NON-RESIDENTIAL BUILDING PERMITS ONLY:
Is the applicant or future building occupant required to submit a business plan, acutely hazardous materials registration form or risk management and prevention
program under Sections 25505, 25533 or 25534 of the Presley-Tanner Hazardous Substance Account Act? □ 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? D Yes D No
Is the facility to be constructed within 1,000 feet of the outer boundary of a school site? □ Yes □ No
IF ANY OF THE ANSWERS ARE YES, A FINAL CERTIFICATE OF OCCUPANCY MAY NOT BE ISSUED UNLESS THE APPLICANT HAS MET OR IS MEETING THE
REQUIREMENTS OF THE OFFICE OF EMERGENCY SERVICES AND THE AIR POLLUTION CONTROL DISTRICT.
APPLICANT CERTIFICATION:
I certify that I have read the application and state that the above information is correct and that the information on the plans is accurate. I agree to comply with all
City ordinances and State laws relating to building construction.
I hereby authorize representative of the City of Carlsbad to enter upon the above mentioned property for inspection purposes. I ALSO AGREE TO SAVE, INDEMNIFY AND KEEP
HARMLESS THE 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 80 ys tion 106.4.4 Uniform Building Code).
1635 Faraday Ave Carlsbad, CA 92008
B-1
Ph: 760-602-2719 Fax: 760-602-8558
Page 2 of2
Email: Building@carlsbadca.gov
Rev. 06/18
' '
PERMIT INSPECTION ,HISTORY for: (CBR2020-0520)
Permit Type: BLOG-Residential Application Date: 03/03/2020 Owner: ROBERT HOM
Work Class: Pool Issue Date:
Status: Closed -Finaled Expiration Date:
IVR Number:
Scheduled Actual Inspection Type Inspection No.
Date Start Date
Tuesday,August1,2023
Checklist Item
BLDG-Building Deficiency
BLDG-Plumbing Final
BLDG-Mechanical Final
BLDG-Structural Final
BLOG-Electrical Final
COMMENTS
06/02/2020 Subdivision: CARLSBAD TCT#97-16A KELLY
RANCH CORE
12/18/2023 Address: 2170 TWAIN AVE
25157 CARLSBAD, CA 92008-4617
Inspection Primary Inspector Reinspection Inspection
Status
Passed
Yes
Yes
Yes
Yes
Yes
Page 3 of 3
' "" '"'8'.°' "'
PERMIT INSPEC'tIO..., Hl~TOI\Y for (CBR2020-0520)
Permit Type: BLDG-Residential
Work Class: Pool
Application Date: 03/03/2020 Owner: ROBERT HOM
Issue Date: 06/02/2020 Subdivision: CARLSBAD TCT#97-16A KELLY
Status:
Scheduled
Date
10/05/2020
04/30/2021
06/05/2023
06/21/2023
07124/2023
07/27/2023
Closed -Finaled Expiration Date: 12/18/2023
IVR Number: 25157
RANCH CORE
Address: 2170 TWAIN AVE
CARLSBAD, CA 92008-4617
Actual Inspection Type
Start Date
Inspection No. Inspection
Status
Primary Inspector Reinspection Inspection
BLDG-53
Elec/Conduit/Wiring{Po
ols)
139960-2020
BLDG-54 Equipotential 139961-2020
Bond(Pools)
10/05/2020 BLDG-23 140046-2020
Gas/Test/Repairs
Checklist Item COMMENTS
Passed Chris Renfro
Passed Chris Renfro
Passed Chris Renfro
BLDG-Building Deficiency Video inspection completed 10/05/2020. Ok
to backfill
04/30/2021 BLDG-54 Equipotential 156364-2021 Failed Chris Renfro
Bond(Pools)
Checklist Item COMMENTS
BLDG-Building Deficiency No further work or inspections until
retaining wall and deck on slope
addressed. Not per plans
06105/2023 BLDG-54 Equipotential 213104-2023 Passed
Bond(Pools)
Checklist Item COMMENTS
TEXT
BLDG-Building Deficiency
NOTES Created By
Angie Teanio 760-643-6078 Roger
06/21/2023 BLDG-55 214975-2023
Fence/Prep laster
Checklist Item COMMENTS
BLDG-Building Deficiency
07/24/2023 BLDG-Final Inspection
Checklist Item
218331-2023
COMMENTS
Passed
Cancelled
BLDG-Building Deficiency
BLDG-Plumbing Final
BLDG-Mechanical Final
BLDG-Structural Final
BLDG-Electrical Final
Canceling nobody on site or home
07/27/2023 BLDG-Final Inspection 218839-2023 Passed
Chris Renfro
Chris Renfro
Chris Renfro
Chris Renfro
Complete
Complete
Complete
Passed
Yes
Reinspection Incomplete
Passed
No
Complete
Passed
Yes
Created Date
06/02/2023
Complete
Passed
Yes
Reinspection Incomplete
Passed
No
No
No
No
No
Complete
Tuesday,August1,2023 Page 2 of 3
Building Permit Inspection History Finaled
(City of
Carlsbad
'
PERMIT INSPECTION HISTORY for (CBR2020-0520)
Permit Type: BLDG-Residential
Work Class: Pool
Application Date:
Issue Date:
03/03/2020
06/02/2020
Owner: ROBERT HOM
Subdivision: CARLSBAD TCT#97-16A KELLY
RANCH CORE
Status:
Scheduled
Date
06/11/2020
07/2112020
07/23/2020
07/2412020
08/25/2020
08/26/2020
10/02/2020
Closed -Finaled Expiration Date: 12118/2023 Address: 2170 TWAIN AVE
IVR Number: 25157 CARLSBAD, CA 92008-4617
Actual Inspection Type
Start Date
06/11/2020 BLDG-SW-Pre-Con
Checklist Item
Inspection No,
129841-2020
COMMENTS
Inspection Primary Inspector
Status
Passed Chris Renfro
BLOG-Building Deficiency
07/2112020 BLDG-51 133351-2020 Cancelled Chris Renfro
Excav/Steel(Pools)
Checklist Item COMMENTS
BLDG-Building Deficiency
BLDG-52 Pool Plumbing 133350-2020 Cancelled Chris Renfro
07123/2020 BLDG-51 133607-2020 Failed Chris Renfro
Excav/Steel(Pools)
Checklist Item
BLOG-Building Deficiency
COMMENTS
Please refer to plans for correct raised
bond beam rebar size. Plans call for (3) #4
rebar not (3)#3 rebar.
BLDG-52 Pool Plumbing 133606-2020 Passed Chris Renfro
07/2412020 BLDG-51 133768-2020 Passed Paul Burnette
Excav/Steel{Pools}
Checklist Item
BLDG-Building Deficiency
COMMENTS
Please refer to plans for correct raised
bond beam rebar size. Plans call for (3) #4
rebar not (3)#3 rebar.
08125/2020 BLDG-11 136584-2020 Failed Peter Dreibelbis
Foundation/Ftg/Piers
(Rebar)
Checklist Item
BLDG-Building Deficiency
COMMENTS
No details for wall construction, requests
clarification
08126/2020 BLDG-11 136682-2020 Failed Peter Dreibelbis
10/02/2020
Foundation/Ftg/Piers
(Rebar)
Checklist Item
BLOG-Building Deficiency
COMMENTS
No details for wall construction, requests
clarification
Reinspection Inspection
Complete
Passed
Yes
Reinspection Incomplete
Passed
No
Re inspection Incomplete
Reinspection Incomplete
Passed
No
Complete
Complete
Passed
Yes
Reinspection Incomplete
Passed
No
Reinspection Incomplete
Passed
No
Tuesday,August1,2023 Page 1 of 3
STORM WATER COMPLIANCE FORM
TIER 1 CONSTRUCTION SWPPP ( ·.i-:-: {:'., , __ ;) ( _; ,")/\ -, .. ( -•"-) /) ( .:, i:-r ~,
STORM WATER POLLUTION PREVENTION NOTES BEST MANAGEMENT PRACTICES (BMP) SELECTION TABLE
Erosion Control Sediment Control BMPs Tracking Non-Storm Water Waste Management and Materials
1. ALL NECESSARY EQUIPMENT AND MATERIALS SHALL BE BMPs Control BMPs Management BMPs Pollution Control BMPs
AVAILABLE ON SITE TO FACILITATE RAPID INSTALLATION C
OF EROSION AND SEDIMENT CONTROL BMPs WHEN RAIN C C 0 --0 0 :;::; C C "O ,:;:; :;::; "' 0 <1> "O <1> "O
IS EMINENT. "' C 0 0 C £ "' E C E C -0 :, :, 0 ·.: a. 0 0 0 E -L L :;::; "O L ·:5 <1> <1>
THE OWNER/CONTRACTOR SHALL RESTORE ALL EROSION ::,e "O "' "' L <1> ---~ -:::. >, "' -2. C <1> L <1> c "' "' "' 0 CT L 0 C "' Q)
"' a. <1> £ C > L L ~ 0 0 -Best Management Practice* .;:i C o-a 0 ·.: -C en L (!) <1> w C "'
CONTROL DEVICES TO WORKING ORDER TO THE SATISFACTION '" [Il a. L 0 <1> 0 <1> <1> 0 -:;:; -:;,:-o-:c "' "' ~ <1> 0 C OL u -~ .s E "' ~ "O "' ::,e C <1> C C 3:: C
(BMP) Description ➔ "' 0 <1> (/) "' "' <1> "' [Il "6 C "' C "O "' C ~ _., "'<1> <1>
OF THE CITY INSPECTOR AFTER EACH RUN-OFF PRODUCING <1> "5 ~ (I} Js <1> -0 0 S< C -oW "O >, 0"' Cc
0 "'
0 :::> gi E 0 0 LO 0o Q) " E ., E
:;::; C 0 [Il (/) ·-"' □:;:; .,, il 0 0<1> <1>
RAINFALL. X ::,e 0 "' C <1> ct:: _E 0 N en 0 en:;:; Q) <1> C c"' c ~ L-3:: Q) 0 <1> -Q)
0 <1> .D E~ :..::;: (/) :.=: :5: L"-:0 0 -;:: ·-"' ·.: ~_g "' 1: "' ~ "' <1> ,., "-E u §! <1> :, c0 LO ..,, -"O .C C L "O ·-<1> :a --0 Q)" 0 <1> "O 0 o0 0 0
t:: ·a g. '5 <1> :, L-.0 L •-L ·-0 <1> L " 3. THE OWNER/CONTRACTOR SHALL INSTALL ADDITIONAL EROSION
0 0 -<1> <1> 0 LO C 00 0 "'
o0 -o ~ :g -.c Q) -o -0 = C •-C NC CC
<1> ~ 0L Vi <1> .c .D L -o 0 -L U) C -o OL 0 ~B o_ 0 -a. 0 Q0 0 0 Q0
(!) WO in (/) 0 [;: (!) (/) > (f) (/) "-(/) ct:: 3:: "-o_o 0.. ::,e (/) ::,e (f) (/) u (/) ::,e :c::,e u::,e
CONTROL MEASURES AS MAY BE REQUIRED BY THE CITY
INSPECTOR DUE TO INCOMPLETE GRADING OPERATIONS OR CASQA Designation ➔ r--IX) "' ~ .... 0 N "' r--IX) 'T N "' ... "' (0 IX)
"T -"' "' (0 r--IX) 'T 'T 'T I I I I I I
UNFORESEEN CIRCUMSTANCES WHICH MAY ARISE.
I I I I I I I I I I I I I I
0 u u 0 w w w w w w w w ct:: ct:: (/) (/) (/) (/) I ::,e I ::,e ::,e ::,e ::,e
Construction Activity w w w uJ (/) (/) (/) (/) (/) (/) (/) (/) I-I-z z z z 3:: 3:: 3:: 3:: 3::
4. ALL REMOVABLE PROTECTIVE DEVICES SHALL BE IN PLACE ,..., Gradinn /Soil Disturbance ''" "-
AT THE END OF EACH WORKING DAY WHEN THE FIVE (5) -./ Trenchinn /Excavation '·~ .,.,
DAY RAIN PROBABILITY FORECAST EXCEEDS FORTY PECENT V . Stockoilina ' -><-.
( 40%). SILT AND OTHER DEBRIS SHALL BE REMOVED AFTER Drill inn IBorinn
EACH RAINFALL. "'V Concrete/Asohalt Sawcuttina X
5. ALL GRAVEL BAGS SHALL CONTAIN 3/4 INCH MINIMUM " Concrete Flatwork ),.
' Pavinq \.,
AGGREGATE. Conduit/Pioe Installation
6. ADEQUATE EROSION AND SEDIMENT CONTROL AND PERIMETER Stucco/Mortar Work
PROTECTION BEST MANAGEMENT PRACTICE MEASURES MUST I'-Waste Disoosal "'
BE INSTALLED AND MAINTAINED. Stan in a /Lav Down Area '
Eaui□ment Maintenance and Fuelina
7. THE CITY INSPECTOR SHALL HAVE THE AUTHORITY TO ALTER Hazardous Substance Use/Storaae
THIS PLAN DURING OR BEFORE CONSTRUCTION AS NEEDED Dewaterina , TO ENSURE COMPLIANCE WITH CITY STORM WATER QUALITY Site Access Across Dirt
REGULATIONS. Other (iistl:
Instructions: 1. Check the box to the left of all applicable construction activity (first column) expected to occur during construction.
2. Located along the top of the BMP Table is a list of BMP's with it's corresrionding California Stormwater Quality Association (CASQA) designation number. Choose one
or more BMPs you intend to use during construction from the list. Check he box where the chosen activity row intersects with the BMP colu.mn.
3. Refer to the CASQA construction handbook for information and details of the chosen BMPs and how to apply them to the project.
OWNER'S CERTIFICATE:
I UNDERSTAND AND ACKNOWLEDGE THAT I MUST: (1) IMPLEMENT
BEST MANAGEMENT PRACTICES (BMPS) DURING CONSTRUCTION PROJECT INFORMATION
ACTIVITIES TO THE MAXIMUM EXTENT PRACTICABLE TO AVOID (>0\;, Tw,,1V\ M THE MOBILIZATION OF POLLUTANTS SUCH AS SEDIMENT AND TO Site Address: J.t 10
AVOID THE EXPOSURE OF STORM WATER TO CONSTRUCTION Assessor's Parcel Number: '2,o£, -l2\J ·•L •• ·,-·e,,,J RELATED POLLUTANTS; AND (2) ADHERE TO, AND AT ALL TIMES,
COMPLY WITH THIS CITY APPROVED TIER 1 CONSTRUCTION SWPPP
THROUGHOUT THE DURATION OF THE CONSTRUCTION ACTI~TIES Emergency Contact:
UNTIL THE CONSTRUCTION WORK IS COMPLETE AND APPROVED Name: '6~ \Jtl-e' (LllCt¢"f le lAc·
BY THE CITY OF CARLSBAD. t;.··c -2'17• ~'c: ''""
/',,\ 1 (:\Hie A Co,'IJ'.~o ri
24 Hour Phone: ~ ~· • ) .<,; '2
OWNER(S' mwNER S AGENT NAME (PRINT) A··~' 1h{i0
Construction Threat to Storm Water Quality
(Check Box)
OWNER\:5J/OWNER S AGENT NAME (SIGNATURE/ DATE ~EDIUM □ LOW
E-29 Page 1 of 1 REV 11/17