HomeMy WebLinkAbout1331 KNOWLES AVE; ; CBR2019-1689; PermitBuilding Permit Finaled
Print Date: 08/21/2020
Job Address:
Permit Type:
Parcel#:
Valuation:
Occupancy Group:
#of Dwelling Units:
Bedrooms:
Bathrooms:
Project Title:
1331 KNOWLES AVE,
BLDG-Residential
1561641300
$4,028.64
Residential Permit
CARLSBAD, CA 92008-1548
Work Class:
Track#:
Lot#:
Project#:
Plan#:
Construction Type:
Orig. Plan Check#:
Plan Check#:
Demo
Description: HUELSEBUSCH: DEMO 654 SF HABITABLE
FEE
BUILDING PERMIT FEE ($2000+)
BUILDING PLAN CHECK FEE (BLDG)
Property Owner:
HUELSEBUSCH MELODY SEPARATE PROPERTY
2004 TRUST
1331 KNOWLES AVE
CARLSBAD, CA 92008
SB1473 GREEN BUILDING STATE STANDARDS FEE
STRONG MOTION-RESIDENTIAL
Total Fees: $121.56 Total Payments To Date: $121.56
(city of
Carlsbad
Permit No: CBR2019-1689
Status:
Applied:
Issued:
Finaled Close Out:
Inspector:
Closed -Finaled
07/01/2019
09/26/2019
Final Inspection: 08/21/2020
Contractor:
BA WORTHING INC
S145 AVENI DA ENCINAS, # STE I
CARLSBAD, CA 92008-4322
(760) 729-3965
Balance Due:
AMOUNT
$70.61
$49.43
$1.00
$0.52
$0.00
Please take NOTICE that approval of your project includes the "Imposition" of fees, dedications, reservations, or other exactions hereafter
collectively referred to as "fees/exaction." You have 90 days from the date this permit was issued to protest imposition of these
fees/exactions. If you protest them, you must follow the protest procedures set forth in Government Code Section 66020(a), and file the
protest and any other required information with the City Manager for processing in accordance with Carlsbad Municipal Code Section
3.32.030. Failure to timely follow that procedure will bar any subsequent legal action to attack, review, set aside, void, or annul their
imposition.
You are hereby FURTHER NOTIFIED that your right to protest the specified fees/exactions DOES NOT APPLY to water and sewer connection
fees and capacity changes, nor planning, zoning, grading or other similar application processing or service fees in connection with this
project. NOR DOES IT APPLY to any fees/exactions of which you have previously been given a NOTICE similar to this, or as to which the
statute of limitation has previously otherwise expired.
Building Division Page 1 of 1
1635 Faraday Avenue, Carlsbad CA 92008-7314 I 760-602-2700 I 760-602-8560 f I www.carlsbadca.gov
Ccicyof
Carlsbad
RESIDENTIAL
BUILDING PERMIT
APPLICATION
B-1
Plan Check cBR2at1 -16£9
Est. Value .f!'-/02.g.,9-
PC Deposit
Date _____,l,.____,_jl_,_/__..,£,,_/i,_t'J,__
Job Address __.l._?iJ.....,,?"-'-l __ k'..._r-.1_o_~____:_Ui.:?..::......,_ _____ .Suite: ____ APN: -'-=5=--b_-_l_.l:,_'{,:__, _1 3 __ _
CT/Project #: __________ Lot#: ____ Fire Sprinklers: yes/ no Air Conditioning: yes/ no
BRIEF DESCRIPTION OF WORK: -----"$"--r,:__:;0::..__,:::Dc.cr.,µ=::.:::O-=U=-4f.:.:o:_~-=------',6=~---''1L--!=l:__ _________ _
□ 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
0 Pool/Spa: ____ 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: ___________________________________ _
D Plumbing/Mechanical/Electrical Only: ________________________ _
Other: _..,.bc:::;;=-1-'-----r:i __ ~_-r_D __ D_6<--M._0_LA------'±i'--o_>J _____________ _
APPLICANT (PRIMc:r CONTACT)
Name: e, • 0.., o !2-\:tP"'-4
Address: tzL/o G ?Aho 1/d'e--
City: Cj...uht,-'.h State: q\-
Phone: '7bb '1:i,:t' 34 '-5
Email: !,A,W,b12..(!:t1 '.'¼, 1r-.1t.. e;
PROPERTY OWNER t I
Lu.e, , Name: K~o'{ 'Ht>~~'-~ wse,t(
Address: 1 '.o 3 1 ~1-1.0 W 1,t:1::, Av£.,
Zip: q z_,o~e, City: ~e,4-'.D State: CA Zip: q '2.t>o.S
Phone: __________________ _
'IM-<oo, 4>1'( Email: ________________ _
DESIGN PROFESSIONAL
Name: _________________ _
CONTRACTOR BUSINESS
Name: _~9..,A-«A=t:.-=--..,,.½'-"----'6,=.:.::.u~r':<a:,.;..:..:=+------
Address: ________________ _ Address: __________________ _
City: _______ State:, __ ~Zip: ___ _ City: ________ State: __ ~Zip: ______ _
Phone: _________________ _ Phone: ___________________ _
Email: _________________ _
Architect State License: ___________ _
Email: ___ ~~-~=------------
State License: 5'll3 1bil Bus. License: Bl:tJ/l':'M"lUO
{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 7031.5 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.
!1 have and will maintain worker's compensation, as required by Section 3700 of the Labor Code, for th~erfoP.ance of the work for which this permit is issued.
My workers' c pensation insurance carrier and policy number are: lnsura'}'f Crpany Name: __ C-:::...'{....::._.:_J!____,~:::6-=:._,'.:J'------------------
Policy No. D.-w I -z_ Expiration Date:---'''-"''---"-' _.j,....::m=----
□ 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 addition the to the cost of compensation, damages as provided for in Section 3706 of the Labor Code,
Interest and attorney's fees. rll .. .,, ~ •
CONTRACTOR SIGNATURE: __ v"l---.. ____ r_"'_ '--..:> __________ □AGENT DATE:
( 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).
□ l, 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).
□ 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. l (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: □AGENT ----------------------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 □ 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? □ 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 l 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 S'O' deep and demolition or construction of structures over 3 stories in height.
EXPIRATION: Every permit issued by the Building Official under the provisions ofthis 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).
/i) ' n...:--
APPLICANT SIGNATURE: --~-----------------DATE: _-t~{_t .,_{ _I 'f-'-----
1635 Faraday Ave Carlsbad, CA 92008
B-1
Ph: 760-602-2719 Fax: 760-602-8558
Page 2 o/2
Email: Building@carlsbadca.gov
Rev. 06/18
Building Permit Inspection History Finaled
(City of
Carlsbad
PERMIT INSPECTION HISTORY for {CBR2019-1689)
Permit Type: BLDG-Residential
Work Class: Demo
Status: Closed -Finaled
Application Date: 07/01/2019 Owner: TRUST HUELSEBUSCH MELODY
SEPARATE PROPERTY 2004 TRUST
Issue Date: 09/26/2019 Subdivision:
Expiration Date: 03/24/2020
IVR Number: 20079
Address: 1331 KNOWLES AVE
CARLSBAD, CA 92008-1548
Scheduled Actual Inspection Type Inspection No. Inspection Primary Inspector Reinspection Inspection
Date Start Date Status
08/21/2020 08/21/2020 BLDG-Final Inspection 136379-2020 Passed Peter Dreibelbis Complete
Checklist Item COMMENTS Passed
BLDG-Structural Final No
Friday, August 21, 2020 Page 1 of 1
S[p 2 6 20/9
( ,-,
DEMOLITION ASBESTOS CERTIFICATION ' '
ADDRESS: 1?'31 l<cJowlez
:·.:,'!:\[)
;1 i,'J
USE OF BUILDING TO BE DEMOLISHED: t qoo ~ ~ ?f=P
SQUARE FEET '1.9m ?9 fl X NUMBER OF STORIES -~'---
PROPERTY OWNER: O'.)~lodv1 w.J:eJ~_;h.
ADDRESS: \ '3,S'!,\ Kf-low]Y, / ~w: PHONE 7{d) -'-'-'-------
APPLICANT: ~~\t'i~
ADDRESS: pl~\k f?NL\~ C6<\~ Gt,-PHONE7Ct:07zq 3q(o5'
I I
Section 19827.5 of Callfornla Health and Safety Code states in part:
"A demolition permit shall not be issued by any city ... as to any building or other
structure except upon receipt from the permit applicant of a copy of each written
asbestos notification regarding the bulldlng that has been required to be submitted
to the United States Environmental Protection Agency or to a designated state
agency, or both, pursuant to Part 61 of Title 40 of the Code of Federal Regulations,
or the successor to that part. The permit may be issued without the applicant
submitting a copy of the written notification If the appllcant declares that the
notification is not applicable to the scheduled demolition project."
As applicant for a demolition permit in the City of Carlsbad, I certify that; I have
read the excerpt from Section 19827.5 of the Health and Safety Code provided
above; the information I have provided on this form is true and correct; and I further
certify the following:
( )
On the attached ___ pages are copies of all written asbestos notifications
regarding the above referenced building that are required to be submitted to
the United States Environmental Protection Agency or to Part 61 of Title 40
of the Code of Federal Regulations, or successor to that part.
I declare that the written asbestos notification is not applicable to the
scheduled demolition project.
Date
Rev. 11/12118
SAN DIEGO REGIONAL
HAZARDOUS MATERIALS
QUESTIONNAIRE
OFFICE USE ONLY
RECORD ID# ________________ _
PLAN CHECK# _______________ _
BP DATE
Telephone#
Zip Code APN#
Plan File#
Project Contact~.... J.,, 1 • J.,.. ~ \ A.~.,.._ , Applicant E-mail ., Telephone#
i;;,y 00~7 vv"v-d"V)" ~ \:>,..OaMI ...i --n,,~ 1 ~ eAUJ'D.IL-. cam.
The following questi represent the facili s activities, NOT the specific project description.
PART I: FIRE DEPARTMENT -HAZARDOUS MATERIALS DIVISION: OCCUPANCY CLASSIFICATION: not re uired for ro'ects within the Ci of San
Diego): Indicate by circling t e 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):
13. Corrosives 1. Explosive or Blasting Agents
2. Compressed Gases
5. Organic Peroxides 9. Water Reactives
6. Oxidizers 1 0. 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 11: SAN DIEGO COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH -HAZARDOUS MATERIALS DIVISION (HMDl: 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 110, San Diego, CA 92123.
Call (858) 505-6700 prior to the issuance of a building permit.
Expected Date of Occupancy: FEES ARE REQUIRED Project Completion Date:
(for new construction or remodeling projects)
Is your business listed on the reverse side of this form? (check all that apply).
□ CalARP Exempt
I
1.
2.
3.
4.
5.
6.
7.
8.
YES NO
□ ~ 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? □ llil'
□ □ □ □ □
I Will your business store or handle carcinogens/reproductive toxins in any quantity?
Will your business use an existing or install an underground storage tank?
Will your business store or handle Regulated Substances (CalARP)? W Will your business use or install a Hazardous Waste Tank System (Title 22, Article 1 0)? ~ Will your business store petroleum in tanks or containers at your facility with a total facility storage capacity equal to
or reater than 1,320 allons? California's Above round Petroleum Stora e Act .
Date Initials
□ CalARP Required
I
Date Initials
□ CalARP Complete
I
Date Initials
PART 111: SAN DIEGO COUNTY AIR POLLUTION CONTROL DISTRICT (APCDl: Any YES" answer requires a stamp from APCD 10124 Old Grove Road, San
Diego, CA 92131 apcdcomp@sdcounty.ca.gov (858) 586-2650). ["No stamp required if 01 Yes and 03 Yes fill9 04-06 No]. The following questions are intended
to identify the majority of air pollution issues at the planning stage. Projects may require additional measures not identified by these questions. For comprehensive
requirements contact APCD. Residences are typically exempt, except -those with more than one building+ on the property: single buildings with more than four
dwelling units: townhomes: condos; mixed-commercial use; deliberate burns; residences forming part of a larger project. [+Excludes garages & small outbuildings.]
1.
2.
3.
4.
5.
6.
YES .,,NO D ·.etf Will the project disturb 160 square feet or more of existing building materials? D _a Will any load supporting structural members be removed? Notification may be required 10 working days prior to commencing demolition. D ff (ANSWER ONLY IF QUESTION 1 or 2 IS YES) Has an asbestos survey been peliormed by a Certified Asbestos Consultant or Site Surveillance
□
□
□
Technician? ~(ANSWER ONLY IF QUESTION 3 IS YES) Based on the survey results, will the project disturb any asbestos containing material? Notification
may be required 10 working days prior to commencing asbestos removal. 5' Will the project or associated construction equipment emit air contaminants? See the reverse side of this form or APCD factsheet
(www.sdapcd.qrg/info/factslpermits.pdf) for typical equipment requiring an APCD permit.
Bc-1ANSWER ONLY IF QUESTION 5 IS YES) Will the project or associated construction equipment be located within 1,000 feet of a school
bounda
Briefly describA hw~in~c:.c:. i::1rti\liti,:,,c:.· .,
Date
FOR OFFICAL USE ONLY: FIRE DEPARTMENT OCCUPAN,"-.!.~!>"SIFICATION:. ______________ __c:::::,_ ________________ _
BY DATE· I I
EXEMPT OR NO FURTHER INFORMATION REQUIRED RELEASED FOR BUILDING PERMIT BUT NOT FOR OCCUPANCY RELEASED FOR OCCUPANCY
COUNTY-HMO* (""CD) COUNTY-HMO APCO COUNTY-HMO APCD
*A stamp in this box~ exempts businesses from completing or updating a Hazardous Materials Business Plan. Other permitting requirements may still apply.
HM-9171 (08/15) County of San Diego -DEH -Hazardous Materials Division
8291 AERO PLACE, SUITE 160, SAN DIEGO, CA 92123 t 858 258 1500 I fax 858 268 1525
June 10,2019
Ma. Alena Blaslo
B.A. Worthing, Inc
640 Grand Avenue Suite G
Carlsbad, CA 92008
Prqect:
SUl,Ject:
Dear Ma .. Blulo,
1331 Knowles Ave, Carlsbad, CA 92008
Albe11D1 & Lead Abatement
www.W11tkl1uErivlro.eo-m CA l.cense #966..J.6"
a.-,0.143499
Phone: (760) 729-3965
Fax:
E-mail: baworlhlnglnc@yahoo.com
Walkins Environmental Is pleased to provide you with Ila following quote for work on your project. our quota la based on the
following Work to be Performed, llama Included In Quote, Item■ Excluded from Quote, and General Condhlons of Cuota.
Work to be Perlarmad
Remove and dl■poee of the aabeatoa containing roofing mntlc & window putty as ldanUfled and quanUled In Ila Aabaatoa
Survey and Lead Paint lnspecllon report praparad·by GES tlcdatad Dec, 2018.
In addllon, scrape and encapsulale the looee and flaky lead-bued paint as ldantlfled and quantified In Iha Aabeslo8 Sul'V8)'
and Lead Paint lnspecllon report prepared by GES Inc dated Dec, 2018.
Watkin■ will remove and dl■poee of all doer■ & frames and windows & frames In their anUraty, since they contain both lead &
aabestoa.
Exdudea the removal of any lead In goodnntact condlUon. DemoliUon conlnlctor will need to perform a w88119 characlarlzaUon
■ample lo detarmlne where Ila waata may ba disposed at
0.. Price for .... Work
$3,875.00
This quota Is valid for 30 days from the data of the quofll. I you do not noUly Watkins Environmental, Inc. with a no1lce ol ln1Bnt
lo award or Issue a contract within Iha 3lklay period, wa retain the right to revlsa our price and ra-submlL This quote Is
subject to any regulatory cost changes and lnduslry cost Increases that would require a modlftcaUon lo the quofll. All work will
ba performed In S1rict compliance with all Federal, Stafll and Local regulations.
We appniclata the opportunity to quota on your project. ff I can ba of any further assistance, pleaee do not hesltata lo call me
at (858) 288-1500.
Sincerely,
Bryn Bulolph
soqf
•~Sempra Energy u1n1ty"
Notice of Service Discontinuance
PERMIT DEPARTMENT, CITY OR COUNTY OF: CARLSBAD
SERVICE WILL BE DISCONTINUED TO:
ADDRESS: 1331 KNOWLES AVE. CARLSBAD
BY: (Date) September 261 2019
181 ELECTRIC METER NO. -'0=5=23=5=82=5'--------
181 GAS METER NO. ....,0=0.::92==2'-"48:..:.7 _____ _
ALL SERVICE LINES WILL BE REMOVED. THIS BUILDING CAN BE MOVED OR
RAZED AFTER THE ABOVE DATE.
\
PHONE: 760-476-5611
DATE: September 26, 2019
PM Forms: NotlceofServlceDlscontlnuance (BLANK)NC
I
',, 'I
Revised: I
C Cityof
Carlsbad
CONSTRUCTION WASTE
MANAGEMENT PLAN
B-59
Development Services
Building Division
1635 Faraday Avenue
760-602-2719
SEP .2;s ~om www.carlsbadca.gov
I j -,, '
Many of the materials generated from your project can be recycled. You are required to list~m~terial s t hat will be
reused, recycled or disposed from your project. If you have questions about the recycling requirement or completing
this form, please contact Wast e Management at (760) 929-9400, a certified C&D recycler, or the Carl sbad Building
Division at (760) 602-2700. Please note: Unless you are self-hauling, Waste Management or approved haulers must be
used for all construction projects within the City of Carlsbad.
PART 1 Complete and submit this form when applying for a Building Permit. Note: Permits will not be issued
without a completed Construction Waste Management Plan.
Permit No.---=-.,,,_f?>LLR+, :l~G'R...L.L...:ll----\.J--b"""'--'..1$9J-'--ProjectTitle l~vel 2eb.>~l--t \-lowt:e 6
Project Address\?f3\ KNOW \-e.', rw e Ctcl~~ 1 (J!:s q-zooe APN I Sta I hLf 13 <J
ApplicantName Wor<fu,N£\' ) ev-,a:;k7 0 Co&r Ac.r 0------
lost <.J First
Applicant Address _5=--..:,_\ 4:2~-----!.:t,..,:....:....=ffi:....:.\-=· ~~-=-~_:__d_
1
_N:-'-~..L,__.J--} _,,W-=..:,_=1~....:.cw:..:....c......_,1--fAr:c....:,_. _ __,4'-"'vx:fo~----
Phone c1{p()) 72'1 2tf (p5 E-mail Address bdm~rJ €2 \h\7 ~~ ~J :;tNL .. C..~
Applicant Mailing Address 51+8 tbfetJ 1 ck----€t-..1dN~ fAcc/ '?P~ f Cs , Cf~
(if different than project address)
Project Type
(check all that apply):
Brief Description
Res~al Co□cial Public Building □ Industrial □
1<-@Wb\Jf c?4Ct+#I'~ \took£ l ~\\A,~ ho\Jb'e...-
Project Size. ___________ Estimated Cost of Project $ __ 4=-'-=1---"S_,...1 .... 0'-"(X)"-=-----------
(square footage)
Please check the appropriate box:
□ I plan on using WASTE MANAGEMENT roll-off bin(s) for all materials and will provide all receipts after construction.
~I plan on self-hauling to a certified recycling facility and will provide all receipts after construction.
□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 t o construction and demolition debris generated only from the project listed
in PART 1, that I have reviewed the accuracy of the information, and that the information is true and correct to the
best of my knowledge and belief.
Print Name -e<cd<2'. IJ.Jo<,Jf;; j
Page 1 of 4 Rev. 11/12/18
PART 1 Complete, obtain signature, and submit this form when applying for a Building Permit. Note: Permits will
(cont'd) not be issued without a completed Construction Waste Management Plan.
DEBRIS RECYCLING ESTIMATE:
-PermitNo. Project Title Huel~e~~ lJ&~
Project Address \"?o\ Kr-low \el? ~~ < Ohr~ , {A,_ APN
IAlN"H , ... ,~ --~~ I (7ft,O) 7z_q y:,rpS Applicant Name I~ 1')/1 Phone
l \ /
,
Last First
-•=--••tni.•: Complete the following table with estimated waste tonnage to be generated by your project.
This is your plan for construction waste management. Changes can be made on the final recycle report.
Goal: the diversion rate shall be 65% by weights of debris.
A B C
Material Type Estimated Place a ( ✓) check Place a (✓) check next Place a(✓) check next
Waste Quantity next to items to be to items to be to items to be
(tons) reused or salvaged recycled disposed at landfill
Complete this line of the table only if
only using WASTE MANAGEMENT
roll-off bins. 2?,~0 Mixed C&O Debris
Asphalt & Concrete 70
Brick/ Masonry/ Tile
Mixed Inert Debris
Cabinets, Doors, Fixtures,
Windows (circle all that apply)
Carnet
Carpet Padding / Foam
Cardboard
Ceiling Tile (acoustic)
Drywall (used, new, scrap) 5 ,17
Landscape Debris (brush, trees,
stumps, etc.) No dirt.
Unpainted Wood & Pallets
Roofing Materials ,~~
Scrap Metal
Stucco
Other:
TOTAL -0~.~\ -
--·1=-111111!■•
To meet 65% Diversio n Requirement (estimate) ~.81 X 0 .65 = bB, PB tons
Total Estimated Waste from above Minimum Required Diversion
Contractor/Owner Signature 4..1,~L{ ___, Date q !t-7/11 -~ .
~
Page 2 of 4 Rev. 11/12/18
PART 2 Complete before final inspection, obtain WASTE MANAGEMENT signature, and return with receipts prior to final
building approval.
DEBRIS RECYCLING REPORT {ACTUAL):
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 PART 1, that I have
reviewed the accuracy of the information, and that the information is true and correct to the best of my knowledge
and belief.
Permit No. ________________ Print Name
Address l '.2=' l K'NO\)J le '2
Use this Final Log below to track loads of materials as they leave the job site.
@@SAVE RECEIPTS@@
Indicate FINAL quantities in tons for each material and save receipts and documents from facilities where material is taken.
Additional Project Log pages are available if necessary. Use City Conversion Table to convert volume to tons.
A B C
Date
Example:
01/05/2018
Material Type
Concrete (broken)
@TOTAL
Actual Amt
Reused or
Salvaged
Actual Amt
Recycled
5 tons
Actual Amt
Disposed in
Landfill
Destination Facility
(Name, Address, Phone)
Palomar Transfer Station, 5960 El
Camino Real
-760 603-0153
~ 65%
Diversion Rate Achieved --------~-----------= _____ % :S 65%0
Total of columns A + B Total of columns A+ B + C DIVERSION
Attach the following documentation to this Repor : Return completed form and documentation to:
• Original recycling weight tickets, landfill weight tickets City of Carlsbad
• Original donation receipts with photos and/or itemized de riptio s Building Division (1st Floor)
1635 Faraday Avenue
Carlsbad, CA 92008
• Any other relevant information to support Recycling Report
Page 3 of 4 Rev. 11/12118
.✓
Conversion Table for Common Construction Waste
This document is informational onlv. It is here to help vou convert truckload auantities to tons, if necessarv.
Column A Column B Column C
Category M aterial Volume Tons[Unit Tons
Mixed Debris Construction cy X 0.18 =
Demolition 2(0 cy X 1.19 = ~?3.~n
Asphalt/Concrete Asphalt (broken) cy X 0.70 =
Concrete (broken) 1.'? cy X 1.20 = an
Concrete (solid slab) cy X 1.30 =
Brick/Masonry/Tile Brick (broken) cy X 0.70 =
Brick (whole, palletized) cy X 1.51 =
Masonry brick (broken) cy X 0.60 =
Tile sq ft X 0.00175 =
Building Materials (cabinets, doors, windows, etc.) cy X 0.15 =
Cardboard (flat) cy X 0.05 =
Carpet By square foot sq ft X 0.0005 =
By cubic yard cy X 0.30 =
Carpet Padding/Foam sq ft X 0.000125 =
Ceiling Tiles Whole (palletized) cy X 0.0003 =
Loose cy X 0.09 =
Drywall (new or used) 1/2" (by square foot) sq ft X 0.0008 =
5/8" (by square foot) b8:o sq ft X 0.00105 = 15 I \'7
Demo/used (by cu. yd.) cy X 0.25 =
Landscape Debris (brush, trees, etc.) cy X 0.15 =
Asphalt Composition 1: .Re Shingles, asphalt Shingle cy X 0.22 =
Unpainted Wood/Pallets By board foot bd ft X 0.001375 =
By cubic yard cy X 0.15 =
Trash/Garbage cy X 0.18 =
Other (estimated weight) cy X estimate =
cy X estimate =
cy X estimate =
cy X estimate =
Total all = r:;c::;,81 -to· ~
Page 4 of 4
Rev. 11/12/18