HomeMy WebLinkAbout1330 POINSETTIA LN; ; CB052093; PermitPERMIT APPLICATION
CITY OF CARLSBAD BUILDING DEPARTMENT
1635 Faraday Ave , Carlsbad, CA 92008
1. PROJECT INFORMATION
FOR OFFICE USE ONLY
PLAN CHECK NO ( /(f)f «C<\^-J~r^r
EST VAL /
Plan Ck Deposit
Validated By (
Date
Address (include Bldg/Suite #)Business Name (at this address)
Legal Description Lot No Subdivision Name/Number Unit No Phase No Total # of units
Assessor's Parcel #
Description of Work
2 CONTACT PERSON (if different from applicant)
State/Zip Telephone tt •• •• Fax #Name
3 APPLICANT
d
Contractor [_J
Name
4 PROPERTY OWNER
Name
B CONTRACTOR - COMPANY NAME
(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 is licensed pursuant to the provisions of the Contractor's License Law
IChapter 9, commending with Section 7000 of Division 3 of the Business and Professions Code) or that he 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 I$500))
Name
State License #
Address
License Class
City State/Zip
City Business License #
Telephone tt
Designer Name
State License #
Address City State/Zip Telephone
6; WORKERS' COMPENSATION
Workers' Compensation Declaration I hereby affirm under penalty of perjury one of the following declarations
Q I have and will maintain a certificate of consent to self-insure for workers' compensation as provided by Section 3700 of the Labor Code, for the performance
of the work for which this permit is issued
f~l I have and will maintain workers compensation, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued My worker's compensation insurance carrier and policy number are
Insurance Company Policy No Expiration Date
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS ($100) OR LESS)
CD 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 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 one hundred
thousand dollar* ($100,000), in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor code, interest and attorney's fees
SIGNATURE DATE _____
7 OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason
CD 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
soldwithm 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)
(3 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 contractors! licensed
pursuant to the Contractor's License Law) i
f~l 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 Q YES CD 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 number / 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
number / 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 number / type
of work) ' 2
DATE ZQ'
Mi BUILDINQ'PE'RMITS ONLY
PROPERTY OWNER SIGNATURE
COMPLETE THIS SECTION FOR
Is the applicant or future building occifcaHf 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? Q YES CD NO
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district? CD YES CD NO
Is the facility to be constructed within 1,000 feet of the outer boundary of a school site? Q] YES CD 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
8, : CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 30970) Civil Code)
LENDER'S NAME LENDER'S ADDRESS
9. 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 < omply with all
City ordinances and State laws relating to building construction I hereby authorize representatives 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 PIERMIT
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 thebuilding 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 commerfeedjw a period of 180j*aysjgfeetion 106 4 4 Uniform Building Code) "
APPLICANT'S SIGNATURE
ile/1
DATE
WHITE File/ YELLOW Applicant PINK Finance