HomeMy WebLinkAbout1123 CAMINO DEL SOL CIR; ; CB053102; Permit05-09-2006
Job Address:
Permit Type:
Parcel No:
Valuation:
Occupancy Group:
# Dwelling Units:
Bedrooms:
Project Title:
City of Carlsbad
1635 Faraday Av Carlsbad, CA 92008
Residential Permit Permit No: CB053102
Building Inspection Request Line (760) 602-2725
1123 CAMINO DEL SOL CR CBAD
RAD
0
VN
RESDNTL Sub Type:
2062611700 Lot#:
$117,486.00 Construction Type:
Reference #:
Structure Type:
Bathrooms:
JOHNSTON RES 463 SF ADDITION
500 SF REMOD KITCH/ BATHRM/ NEW WNDOWS
0
0 0
Status:
Applied:
Entered By:
Plan Approved:
Issued:
Inspect Area:
Orig PC#:
Plan Check*:
PENDING
08/29/2005
KG
Applicant:
WORTHING INC, B. A.
SUITE #201
690 CARLSBAD VILLAGE DR
CARLSBAD, CA 92008
619-729-3965
Owner:
TONY AND LAUREN JOHNSTON
1123 CAMINO DEL SOL CR
760-729-3965
Building Permit
Add'l Building Permit Fee
Plan Check
Add'l Plan Check Fee
Plan Check Discount
Strong Motion Fee
Park in Lieu Fee
Park Fee
LFM Fee
Bridge Fee
Other Bridge Fee
BTD #2 Fee
BTD #3 Fee
Renewal Fee
Add'l Renewal Fee
Other Building Fee
HMP Fee
Pot. Water Con. Fee
Meter Size
Add'l Pot. Water Con. Fee
Reel. Water Con. Fee
$602.00 Meter Size
$0.00 Add'l Reel. Water Con. Fee
$391.30 Meter Fee
$0.00 SDCWA Fee
$0.00 CFD Payoff Fee
$11.75 PFF (3105540)
$0.00 PFF (4305540)
$0.00 License Tax (3104193)
$0.00 License Tax (4304193)
$0.00 Traffic Impact Fee (3105541)
$0.00 Traffic Impact Fee (4305541)
$0.00 Sidewalk Fee
$0.00 PLUMBING TOTAL
$0.00 ELECTRICAL TOTAL
$0.00 MECHANICAL TOTAL
$0.00 Housing Impact Fee
?? Housing InLieu Fee
$0.00 Housing Credit Fee
Master Drainage Fee
$0.00 Sewer Fee
$0.00 Additional Fees
TOTAL PERMIT FEES
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,005.05
Total Fees:$1,005.05 Total Payments To Date:$272.68 Balance Due:$732.37
Inspector:
FINAL APPROVAL
Date:Clearance:
NOTICE: Please take NOTICE that approval of your project includes the Imposition" of fees, dedications, reservations, or other exactions hereafter collectively
referred to as lees/exactions." 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 limitations has previously otherwise expired.
PERMIT APPLICATIONCITY OF CARLSBAD BUILDING DEPARTMENT1635 Faraday Ave., Carlsbad, CA 92008 FOR OFFICE USE ONLYPLAN CHECK NPlan Ck. DepositValidated ByDate 5 0002 01Address (include Bldg/Suite ft)Business Name (at this add?Legal Description Lot No.Subdivision Name/Number Unit No.Phase No.Total # of unitsAssessor's Parcel #Existing Use Proposed UseSQ. FT.#of Stories Bathrooms
Name Address City State/Zip Telephone Fax #
Address City
fcB.O:; l-MWirailf l:;r UWWISR s:; i •;•; , is,!-™;;,:,;,; ~£yj£; ; • : •;; ; ;;•,:-,-: •;.; :>fi-.", - •- y. -. -, . :>:: ;••;•• j- •'•/" if.'i : "W '•• 1
' -nDUU-tlAU^NJ tbhM^OrJ H23 /V/rJQ t^| ^fo| W
State/Zip Telephone #
'; j^jpttrn^i"'" ^;j''' -•" '"'-j^^f" * * JKJ!"**/ ^ typJzq
Siate/Zip Telephone ftAddressCityName
SlHiilcpNTfWC^iy-CC^PANi^ME
(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
[Chapter 9, commending with Section 7000 of Division 3 of the Business and Professions Code] or that he is exempt therefrom, and the basts 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]).
City State/Zip
City Business License #
Jesigner Name ,_,
State License » 332#^4
City State/Zip Telephone
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.
MH j 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 %£&£&> ^I't-ft^C Policy No. DQQ$1~T5-'2OQ5 Expiration Date Q/— Of — £>g
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS [$100] OR LESS)
Q 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 dollars {$100,OQ0j7in addftonto the cost of compensation, damages as provided for in Section 3706 of the Labor code. Interest and attorney's fees.
SIGNATURE ^$£flBVVVJ?\/\ S DATE
7, OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from thycohtractor's License Law for the following reason:
Q I, as owner of the property or mv-smproyees 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).
O I' as owner of the property, am exclusively contracting with licensed contractors to construct the project ISec. 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^ licensed
pursuant to the Contractor's License Law).
n 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 l~lNO
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): „__
PROPERTY OWNER SIGNATURE DATE
NO
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? Q YES Q NO
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district? L7I YES
Is the facility to be constructed within 1 ,000 feet of the outer boundary of a school site? Q YES Q 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.
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097(i) Civil Code).
LENDER'S NAME LENDER'S ADDRESS
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 representatives of the City of Carlsbad to enter upon the above mentioned
property for inspection purposes. 1 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^period 0^180 days (Section 106.4.4 Uniform Building Code).
APPLICANT'S SIGNATURE DATE
:Yile YELLOW: Applicant PINK: Finance
May 25, 2006
City of Carlsbad
if •^^•••^•••^^••••^^••^•^••^^••^^^•MBuilding Department
B.A. WORTHING
P O BOX 1041
CARLSBAD CA 92018
RE:
APPLICATION DATE: 08/29/2005
PLAN CHECK #: CB053102
ADDRESS: 1123 CAMINO DEL SOL CR
EXPIRATION DATE: 08/29/2006
PERMIT TYPE: RESDNTL
DESCRIPTION: JOHNSTON RES 463SF ADDITION, 500SF REMO
WINDOWS
You applied to have your plans checked on the date noted above. To date, the related buiWfng
permit has not been obtained. The original plan review application will expire as no building
permit has been issued.
Plans submitted and not retrieved from the building department prior to the plan check
expiration date noted above will be destroyed.
The provisions of sections 304 (d) of the Uniform Building Code state:
"Section 304 9d) Expiration of Plan Review
Applications for which no permit is issued within one year following the date of
application shall expire by limitation, and plans and other data submitted for review
may thereafter be returned to the applicant or destroyed by the Building Official.
In order to renew action on an application after expiration, the applicant shall resubmit
plans and pay a new plan review fee."
In order to provide better service, please indicate your handling choice for the plans originally
submitted and return this letter to the Building Department.
Project Abandoned -1 will pick up the plans within 10 days
/\ Project Abandoned - Plans may be destroyed
If you have any questions, please contact the Building Department at (760) 602-2719.
Building Department
1635 Faraday Avenue • Carlsbad, CA 92OO8-7314 • (76O) 602-27OO * FAX (760) 6O2-856O
EsGil Corporation
In <Partnersfiip witli government for <Bui(<fing Safety
DATE: September 8, 2005 Q APPLICANT
JURIS. JH
JURISDICTION: Carlsbad Q PLAN REVIEWER
Q FILE
PLAN CHECK NO.: CB053102 SET: I
PROJECT ADDRESS: 1123 Camino Del Sol Cir.
PROJECT NAME: Addition and Remodel for the Johnston Residence
The plans transmitted herewith have been corrected where necessary and substantially comply
with the jurisdiction's building codes.
The plans transmitted herewith will substantially comply with the jurisdiction's building codes
when minor deficiencies identified below are resolved and checked by building department staff.
The plans transmitted herewith have significant deficiencies identified on the enclosed check list
and should be corrected and resubmitted for a complete recheck.
The check list transmitted herewith is for your information. The plans are being held at Esgil
Corporation until corrected plans are submitted for recheck.
The applicant's copy of the check list is enclosed for the jurisdiction to forward to the applicant
contact person.
XI The applicant's copy of the check list has been sent to:
Brooks Worthing
P.O. Box 1041 Carlsbad, CA 92018
Esgil Corporation staff did not advise the applicant that the plan check has been completed.
22 Esgil Corporation staff did advise the applicant that the plan check has been completed.
Person contacted: Brooks Worthing Telephone #: (760) 729-3965
Date contacted \lfl/Q^ (to$£) Fax #: (760) 729-0784
Mail Telephone y Fax y In Person
REMARKS:
By: Steve Sanders Enclosures:
Esgil Corporation
D GA D MB D EJ D PC 9/1/05 tmsmtl.dot
9320 Chesapeake Drive, Suite 208 4 San Diego, California 92123 * (858)560-1468 + Fax (858) 560-1576
Carlsbad CB053102
September 8, 2005
PLAN REVIEW CORRECTION LIST
SINGLE FAMILY DWELLINGS AND DUPLEXES
PLAN CHECK NO.: CB053102 JURISDICTION: Carlsbad
PROJECT ADDRESS: 1123 C a mi no Del Sol Cir.
FLOOR AREA: Addition 463 sq. ft. STORIES: 2
Remodel 500 sq. ft.
HEIGHT: 23' Approx.
REMARKS:
DATE PLANS RECEIVED BY DATE PLANS RECEIVED BY
JURISDICTION: 8/29/05 ESGIL CORPORATION: 9/1/05
DATE INITIAL PLAN REVIEW PLAN REVIEWER: Steve Sanders
COMPLETED: September 8, 2005
FOREWORD (PLEASE READ):
This plan review is limited to the technical requirements contained in the Uniform Building Code,
Uniform Plumbing Code, Uniform Mechanical Code, National Electrical Code and state laws
regulating energy conservation, noise attenuation and access for the disabled. This plan review
is based on regulations enforced by the Building Department. You may have other corrections
based on laws and ordinance by the Planning Department, Engineering Department, Fire
Department or other departments. Clearance from those departments may be required prior to
the issuance of a building permit.
Present California law mandates that residential construction comply with the 2001 edition of
the California Building Code (Title 24), which adopts the following model codes: 1997 UBC,
2000 UPC, 2000 UMC and 2002 NEC.
The above regulations apply to residential construction, regardless of the code editions adopted
by ordinance. )
The following items listed need clarification, modification or change. All items must be satisfied
before the plans will be in conformance with the cited codes and regulations. Per Sec. 106.4.3,
1997 Uniform Building Code, the approval of the plans does not permit the violation of any
state, county or city law.
To speed up the recheck process, please note on this list (or a copy) where each
correction item has been addressed, i.e., plan sheet number specification section, etc.
Be sure to enclose the marked up list when you submit the revised plans.
Carlsbad CBO53102
September 8, 2005
Please make all corrections on the original tracings, as requested in the correction
list. Submit three sets of plans for commercial/industrial projects (two sets of plans
for residential projects). For expeditious processing, corrected sets can be
submitted in one of two ways:
1. Deliver all corrected sets of plans and calculations/reports directly to the City of
Carlsbad Building Department, 1635 Faraday Ave., Carlsbad, CA 92008, (760)
602-2700. The City will route the plans to EsGil Corporation and the Carlsbad
Planning, Engineering and Fire Departments.
2. Bring one corrected set of plans and calculations/reports to EsGil Corporation,
9320 Chesapeake Drive, Suite 208, San Diego, CA 92123, (858) 560-1468.
Deliver all remaining sets of plans and calculations/reports directly to the City of
Carlsbad Building Department for routing to their Planning, Engineering and Fire
Departments.
NOTE: Plans that are submitted directly to EsGil Corporation only will not be
reviewed by the City Planning, Engineering and Fire Departments until review by
EsGil Corporation is complete.
1. All sheets of plans must be signed by the person responsible for their
preparation, (California Business and Professions Code).
2. Provide a statement on the Title Sheet of the plans stating that this project shall
comply with the 2001 edition of the California Building Code (Title 24), which
adopts the 1997 UBC, 2000 UMC, 2000 UPC and the 2002 NEC. Please note
the State has adopted the 2002 NEC.
3. Specify roof material. Chapter 15.
4. Show the required ventilation for attics (or enclosed rafter spaces formed where
ceilings are applied directly to the underside of roof rafters). The minimum vent
area is 1/150 of attic area (or 1/300 of attic area if at least 50% of the required
vent is at least 3 feet above eave vents or cornice vents). Show area required
and area provided. Section 1505.3.
5. Show a self-closing door, either 1-3/8" solid core or a listed 20 minute assembly,
for openings between garage and dwelling. Section 302.4. '
6. Provide truss details and truss calculations for this project. Specify truss
identification numbers on the plans.
7. Please provide evidence that the engineer-of-record (or architect) has reviewed
the truss calculation package prepared by others (i.e., a "review" stamp on the
truss calculations or a letter). Section 106.3.4.1.
Carlsbad CB053102
September 8, 20O5
8. Provide calculations for lateral loads, shear panels, shear transfer and related.
Section 106.3.3. This project does not meet the provisions of UBC Section
2320 for Conventional Light-Frame construction. Please provide structural
calculations for this project.
9. Show location of attic access with a minimum size of 22"x30", unless the
maximum vertical headroom height in the attic is less than 30". Access must be
provided to each separated attic area, shall be located in a hallway or other
readily accessible location and 30" headroom clearance is required above the
opening. Section 1505.1.
10. Show the location, type and size (BTU's)of all heating and cooling appliances or
systems.
11. Show on the plans that cbuntertop receptacle outlets comply with NEC Art.
210-52(c), which reads as follows:
In kitchens peninsular countertops 12 inches by 24" long (or greater) shall have
at least one receptacle.
12. Please clarify the method of installation of the electrical outlet shown at the
Kitchen sink.
To speed up the review process, note on this list (or a copy) where each
correction item has been addressed, i.e., plan sheet, note or detail number,
calculation page, etc.
Please indicate here if any changes have been made to the plans that are not a
result of corrections from this list. If there are other changes, please briefly
describe them and where they are located in the plans.
's\
• Have changes been made to the plans not resulting from this
correction list? Please indicate: \
Yes Q No a
The jurisdiction has contracted with Esgil Corporation located at 9320
Chesapeake Drive, Suite 208, San Diego, California 92123; telephone number of
858/560-1468, to perform the plan review for your project. If you have any
questions regarding these plan review items, please contact Steve Sanders at
Esgil Corporation, Thank you.
Carlsbad CB0531O2
September 8, 2005
VALUATION AND PLAN CHECK FEE
JURISDICTION; Carlsbad PLAN CHECK NO.: CB053102
PREPARED BY: Steve Sanders DATE: September 8, 2O05
BUILDING ADDRESS: 1123 Camino Del Sol Cir.
BUILDING OCCUPANCY: R-3 TYPE OF CONSTRUCTION: VN
BUILDING
PORTION
Addition
Remodel
Air Conditioning
Fire Sprinklers
TOTAL VALUE
Jurisdiction Code
Blda, Permit Fee bv Ordina
AREA
(Sq.Ft.)
463
500
cb
Valuation
Multiplier
110.00
City Est.
By Ordinance
— — —^^— ,
nre i v
Reg.
Mod.
VALUE ($)
50,930
15,500
66,430
$410.51
Type of Review:
Q Repetitive FeeRepeats
Complete Review
D Other
. Hourly
Structural Only
Hour*
Esgll Plan Review Fee
$266.83
$229.89
Comments:
Sheet 1 of 1
macvalue.doc
PLANNING/ENGINEERING APPROVALS
PERMIT NUMBER CB DATE
RESIDENTIAL
•' RESIDENTIAL ADDITION MINOR
«$10,OOO.OO»
TENANT IMPROVEMENT
PLAZAlCAMINO^EAC
CARLSBAD COMPANY STORES
VILLAGE FAIRE
COMPLETE OFFICE.BUILDING
OTHER
PLANNER DATE
ENCINEE DATE c <-
PLANNING DEPARTMENT
BUILDING PLAN CHECK REVIEW CHECKLIST
Plan Check No.
Planner Chris Sexton
Address llfl^QgJ
ana, -- I
Phone (760) 602-4624
Type of Project & Use: _
Zoning: R I General Plan: ROD
Net Project Density: •a.DU/AC
CFD (in/out) #_Date of participation:
Facilities Management Zone: _J_
Remaining net dev acres:.
Circle One (For non-residential development: Type of land used created by this
permit:_ )
Leoend: [3 Item Complete Q Item Incomplete - Needs your action
Environmental Review Required: YES NO t-^TYPE
DATE OF COMPLETION:
Compliance with conditions of approval? If not, state conditions which require action.
Conditions of Approval;
Discretionary Action Required:
APPROVALyRESO. NO.
PROJECT NO.
YES NO TYPE
OTHER RELATED CASES:
Compliance with conditions or approval? If not, state conditions which require action.
Conditions of Approval:
O Coastal Zone Assessment/Compliance
Project site located in Coastal Zone? YES i^frlO _
CA Coastal Commission Authority? YES _ NO _
If California Coastal Commission Authority: Contact them at - 7575 Metropolitan Drive, Suite 103,
San Diego CA 92108-4402; (619)767-2370
Determine status (Coastal Permit Required or Exempt): _
Coastal Permit Determination Form already completed? YES _ NO _
If NO, complete Coastal Permit Determination Form now.
Coastal Permit Determination Log #: _
Follow-Up Actions;
1) Stamp Building Plans as "Exempt" or "Coastal Permit Required" (at minimum Floor Plans).
2) Complete Coastal Permit Determination Log as needed.
&Q Q Inclusionary Housing Fee required: YES _ NO -"^
(Effective date of Inclusionary Housing Ordinance - May 21 , 1 993.)
Data Entry Completed? YES _ NO _
(A/P/Ds, Activity Maintenance, enter CB#, toolbar, Screens, Housing Fees, Construct Housing Y/N,
Enter Fee, UPDATE!)
Site Plan:
H:\ADMirJ\COUNTER\adgPlnchkRavChWtt R*vM>1
D D D 1- Provide a fully dimensional site plan drawn to scale. Show: North arrow, property lines
easements, existing and proposed structures, streets, existing street improvements, right-of-way
width, dimensional setbacks and existing topographical lines (including all side and rear yarc
slopes).
D D D 2. Provide legal description of property and assessor's parcel number.
ODD
nan
0rtm
Policy 44 - Neighborhood Architectural Design Guidelines
1. Applicability: YESNO
2. Project complies YES
Zoning:
1 . Setbacks:
Front:
Interior Side:
Street Side:
Rear
Top of slope:
2. Accessory structure sett
Front:
Interior Side:
Street Side:
Rear
Structure separation:
3. Lot Coverage:
NO
Required ftQ *
Required *1 '
Required
Required ffl^ /'
Required
tacks:
Required
Required
Required ^*
Required S*
Required/
^ LLr\ *rRequired rU '
Shown **ft '
Shown S T
Shown
4 ' Shown f£0 '
Shown
Shown
^* Shown >*
^" Shown ^
Shown/
Showfi
<» Shown *^Q7o
Q-Q D •*. Height:
Parking:
Required
Spaces Required
Shown
Shown
3Q
(breakdown by uses for commercial and industrial projects required)
Residential Guest Spaces Required Shown
D CH D Additional Comments,
OK TO ISSUE AND ENTERED APPROVAL INTO COMPUTER
H:\ADMIN^;OUNTER\BldoPtnchkflevChkt8t FtovWDI
iYHOLDER COPY
COMPENSATION
I N S U R A N
P.O. BOX 807, SAN FRANCISCO,CA 94142-0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: O1-01-2005
CITY OF VISTA
ATTN; BUILDING DEPARTMENT
P.O. BOX 1988
VISTA CA 92083
SO
GROUP: OO0048
POLICY NUMBER OOO8775-20OB
CERTIFICATE l& . - 4
CERTIFICATE EXPIRES: 01-O1-200B01-01-2005/01-01-2006
JOB: ALL OPERATIONS
SD
This is to certify that we have issued a vafid Workers' Compensation insurance potiey fri • form approved by the;
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days' advance written notice to the employee
We will also give you 30 days' advance notice should this policy be cancelled prior to its normal expiration. "'.
This certificate of insurance is not an insurance policy and does not amend extend or alter the Coverage afforded
by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document
with respect to which this certificate of insurance may be issued or may pertain, the Insurance afforded by the
policies described herein is subject to all the terms, exclusions and conditions of such policies.
AUTHORIZED REPRESENTATIVE PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 11,000,000.00 PER OCCURRENCE.
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-O1-2008 IS ATTACHED TO AND
FORMS A PART OF THIS POLICY. ;
EMPLOYER LEGAL NAME
\B.A. WORTHING ING.
PO BOX 1041
CARLSBAD CA 92018
B.A. WORTHING, ING.
": ' t '