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Home My WebLink About115 CHANNEL RD; ; CB032297; Permit12-06-2004" V] City of Carlsbad 1635 Faraday Av Carlsbad, CA 92008 Pool Permit Permit No: CB032297 Building Inspection Request Line (760) 602-2725 Job Address: Permit Type: Parcel No: Valuation: Reference #: Project Title: 115 CHANNEL RDCBAD 'POOL 2146000903 Lot#: $2,096.00 Construction Type: NELSON RES 64 SF GUNITE SPA 0 NEW Status: ISSUED Applied: 08/18/2003 Entered By: CB Plan Approved: 09/08/2003 Issued: 09/08/2003 Inspect Area: PD Applicant: SUNDANCER POOLS 728 INPIRATION ESCONDIDO CA 92025 760-489-5850 Owner: NELSON FAMILY TRUST 05-14-94 115 CHANNELRD CARLSBAD CA 92009 Building Permit Add'l Building Permit Fee Plan Check Add'l Plan Check Fee Electrical Fee Plumbing Fee Strong Motion Fee Renewal Fee Add'l Renewal Fee Other Building Fee Additional Fees ' $45.79 $0.00 $29.76 $0.00 $20.00 $27.00 • $1.00 $22.90 $0.00 $0.00 $0.00 TOTAL PERMIT FEES $146.45 Total Fees:$146.45 . Total Payments To Date:$123.55 Balance Due:$22.90 6818 12/06/04 0002 01 02 CGP 22 »90 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 "fees/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. 09-08-2003 City of Carlsbad 1635 Faraday Av Carlsbad, CA 92008 Pool Permit Permit No: CB032297 Building Inspection Request Line (760) 602-2725 Job Address: Permit Type: Parcel No: Valuation: Reference #: Project Title: 115 CHANNEL RDCBAD POOL 2146000903 Lot#: 0 $2,096.00 Construction Type: NEW NELSON RES 64 SF GUNITE SPA Status: ISSUED Applied: 08/18/2003 Entered By: CB Plan Approved: 09/08/2003 Issued: 09/08/2003 Inspect Area: Applicant: SUNDANCER POOLS 728 INPIRATION ESCONDIDOCA 92025 760-489-5850 Owner: NELSON FAMILY TRUST 05-14-94 115 CHANNEL RD CARLSBAD CA 92009 3606 09/08/03 0002 01 02 CGP 93-79 Building Permit Add'l Building Permit Fee Plan Check Add'l Plan Check Fee Electrical Fee Plumbing Fee Strong Motion Fee Renewal Fee Add'l Renewal Fee Other Building Fee Additional Fees TOTAL PERMIT FEES $45.79 $0.00 $29.76 $0.00 $20.00 $27.00 $1.00 $0.00 $0.00 $0.00 $0.00 $123.55 Total Fees: $123.55 Total Payments To Date:$29.76 Balance Due:$93.79 PERMl EXPIRED IN ACCORDANCE DATE. 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 "fees/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. 9-08-2003 job Address'. permit Type'- Lot#- Est complete Date. Trawc° ISSUED 09/08/2003 09/08/2003 12/01/2003 Entered Refer project Title: Description'. 760-489-5850 Total Fees OtherAdditional Fees TOTAL PEH^ 3606 230.00 titeiPayment $230.00 $0.00 $0.00 $0.00 $230.00 PERMIT APPLICATION ' . i CITY OF CARLSBAD BUILDING DEPARTMENT 1635-Faraday Ave., Carlsbad, CA 92008 1. PROJECT INgftt\MATIONl\E> FOR OFFICE USE ONLY PLAN CHECK NO^fo33Z-Z. EST. VAL. Plan Ck. Deposit Validated By Date U~L Address (include Bldg/Suite #)Business. NamaJat this address) Legal Description Lot No.Subdivision Name/Number Unit No.Phase No.Total # of units Assessor's Parcel Existing Use Proposed Use Description of Work 2. CONTACT PERSON {if different from applicant) SQ. FT.#of Stories # of Bedrooms # of Bathrooms 12m 08/18/03 0002 Ql 02 ^76Name 3. APPLICANT Q Contractor- Narne\ 4. Address City t for Contractor Q Owner d Agent for Owner State/Zip Telephone # Address State/Zip Telephone # Nai 5. Address City State/Zip Telephone # 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 [Chapter 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/7j031.5 tkvany applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars [$500])."' SxH.^'C' r~r.^. n I «n s- rv.',^i .-f~,-*^~ i .A /<:>• ^ /'Vi /^>— •>.-> /^~ sir.(~-rT Name State License » MfL Address License Class A). City State/Zip City Business License # Telephone # f^r -/^\ ry £K$ / A Address 'City State/Zip TelephoneDesigner Name State License # 6. WORKERS' COMPENSATION Workers' Compensation Declaration: I hereby affirm under penalty of perjury one of the following declarations: l~l 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.\j> P\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 carcier and policyjiumber are: ,r\ ^i ._ —^ _. Insurance Company ~n[^tLA3L^ ^^TL^-^-.g^V - Policy No. L^ /ilxZ..-^ X / -H3 Expiration Date (THIS SECTION NEED NOT BffcOMPLETED IF Th4 PERMIT IS FOR ONE HUNDRED DOLLARS [$100] OR LESS) l~l 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 dollarsj&IOO.OOO)1, in additioatgnhe cost of compensation, damages as .provided for in Section 3706 of the Labor code, interest and attorney's fees. 7. OWNER-BUIIJDER DECLARATION / J '(O I hereby affirm that I am exempt from the Eontractor's License Law for trie following reason: f~1 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 ovvner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The ComractorJs License Law does not apply to an owner of property who builds or improves thereon, and contracts for such projects with contractor(s) licensed pursuantfo the Contractor's License Law). i exempt under Section Business and Professions Code for this reason: 1. /^personally plan to provide the major labor and materials for construction of the proposed property improvement. Q YES I""|NO 2./ I\have / have not) signed an application for a building permit for the proposed work. I nave 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 COMPLETE Till DATE 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 pfbgram under Sections 25505, 25533 or 25534 of the Presley-Tanner Hazardous Substance Account Act? O YES d NO Is tne applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district? l~l YES Q NO Is thfjnacility to be constructed within 1,000 feet of the outer boundary of a school site? Q YES D 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 Thereby/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 ADDRESSLENDER'S NAME 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 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. 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 commenjea for a geriod ofjfif^da^s (Section 106,4.4 Uniform Building Code). APPLICANT'S SIGNATURE DATE WTE>Ti:ile YELLOW: Applicant LxPINK: Finance City of Carlsbad September 30, 2004 Building Department Permit Number: CB032297 Issue Date: 9/8/03 NELSON RESIDENCE 115 CHANNEL RD 'CARLSBADCA 92008 RE: BUILDING PERMIT EXPIRATION PERMIT TYPE: POOL ADDRESS: 115 CHANNEL RD PLEASE CALL FOR AN INSPECTION IF WORK IS COMPLETE Our records indicate that your building permit will expire by limitation of time on 11/19/04. The provisions of UBC, Section 106.4.4 as amended by the Carlsbad Municipal Code state: "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 (unless issued prior to 7/1/99 which is one year from date of permit), or if the building or work authorized by such permit is stopped at any time after the work is commenced for a period of 180 days or if the building or work authorized by such permit exceeds three calendar years from the issuance date of permit. Work shall be presumed to have commenced if the permittee has obtained a required inspection approval of work authorized by the permit by the Building Official within 180 days of the date of permit issuance. Work shall be presumed to be stopped if the permittee has not obtained a required inspection approval of work by the Building Official within each 180 day period upon the initial commencement of work authorized by such permit. Before such work can be-reeommenced, a new permit shall be obtained to do so, and the fee, therefore, shall be one-half the amount required for a new permit for such work, and provided that no changes have been made or will be made in the original plans and specifications for such work, and provided further that such suspension or abandonment has not exceeded one year. In order to renew action on a permit after expiration, the permittee shall pay a new permit fee. • Any person holding an unexpired permit may apply for an extension of the time within which work may commence under that permit when the permittee is unable to commence work within the time period required by this section for good and satisfactory reasons. The Building Official may extend the time for action by the permittee for a period not exceeding 180 days on written request by the permittee showing that circumstances beyond the control of the permittee have prevented action from being taken. No permit shall be extended more than once. Please check below indicating your intentions and return this letter to us. • Project abandoned. A new permit will be obtained prior to commencing work... No fee extension requested for 180 days, (attach a letter of explanation) Renewal permit requested. If the project has been completed and only a final inspection is needed, please call the inspection request line at (760)602-2725. If you have any questions, please contact the Building Inspection Department at (760) 602-2700. Christine Wauschek Office Specialist . 1635 Faraday Avenue -Carlsbad, CA 92008-7314 - (760) 6O2-2700 • FAX (760) 6O2-8560 City of Carlsbad March 29, 2004 SUNDANGER POOL 728 INSPIRATION ESCONDIDO CA 92025 RE: BUILDING PERMIT EXPIRATION PERMIT TYPE: POOL Building Department Permit Number: CB032297 Issue Date: 9/8/03 ADDRESS: 115 CHANNEL RD PLEASE CALL FOR AN INSPECTION IF WORK IS COMPLETE Our records indicate that your building permit will expire by limitation of time on 5/18/04. The provisions of UBC, Section 106.4.4 as amended by the Carlsbad Municipal Code state: "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 (unless issued prior to 7/1/99 which is one year from date of permit), or if the building or work authorized by such permit is stopped at any time after the work is commenced for a period of 180 days or if the building or work authorized by such permit exceeds three calendar years from the issuance date of permit. Work shall be presumed to have commenced if the permittee has obtained a required inspection approval of work authorized by the permit by the Building Official within 180 days of the date of permit issuance. Work shall be presumed to be stopped if the permittee has not obtained a required inspection approval of work by the Building Official within each 180 day period upon the initial commencement of work authorized by such permit. Before such work can be recommenced, a new permit shall be obtained to do so, and the fee, therefore, shall be one-half the amount required for a new permit for such work, and provided that no changes have been made or will be made in the original plans and specifications for such work, and provided further that such suspension or abandonment has not exceeded one year. In order to renew action on a permit after expiration, the permittee shall pay a new permit fee. Any person holding an unexpired permit may apply for an extension of the time within which work may commence under that permit when the permittee is unable to commence work within the time period required by this section for good and satisfactory reasons. The Building Official may extend the time for action by the permittee for a period not exceeding 180 days on written request by; the permittee showing that circumstances beyond the control of the permittee have prevented action from being taken. No permit shall be extended more than once. Please check below indicating your intentions and return this letter to us. Project abandoned. A new permit will be obtained prior to commencing work. No fee extension requested for 180 days, (attach a letter of explanation) Renewal permit requested. If the project has been completed and only a final inspection is needed, please call the inspection request line at (760)602-2725. If you have any questions, please contact the Building Inspection Department at (760) 602-2700. PATKELLEY Building and Code Enforcement Manager 1635 Faraday Avenue • Carlsbad, CA 92008-7314 • (76O) 6O2-2700 • FAX (760) 6O2-8560 City of Carlsbad Bldg Inspection Request For: 12/07/2004 Permit* CB032297 Title: NELSON RES 64 SF GUNITE SPA Description: Inspector Assignment: PD 115 CHANNEL RD Lot Type: POOL Sub Type: Job Address: Suite: Location: APPLICANT SUNDANCER POOLS Owner: NELSON FAMILY TRUST 05-14-94 Remarks: GATE CODE 7634 CARD LEFT BY SPA Phone: 6264836382 Inspect Total Time: CD Description 59 Final Pool Requested By: VIVIAN Entered By: JANEAN Comment Associated PCRs/CVs Inspection History Date Description Act 08/02/2004 59 Final Pool NS 07/20/2004 59 Final Pool CO 11/19/2003 55 Fence/Pre-Plaster AP 10/01/2003 23 Gas/Test/Repairs AP 10/01/2003 31 Underground/Conduit-Wiring AP 09/30/2003 23 Gas/Test/Repairs CO 09/30/2003 52 Underground Plumbing CO 09/30/2003 53 Electric/Conduit/Wiring CO 09/23/2003 51 Excav/Steel/Bonding/Fence AP Insp Comments PD CALLED SUNDANCER POOLS WITH CORRECTIONS PD PD JM NO RECORD CARD JM JM JM SEE LIST ATTACHED JM GATE CODE *0051 PD City of Carlsbad Bldg Inspection Request For: 08/02/2004 Permit* CB032297 Title: NELSON RES 64 SF GUNITE SPA Description: Inspector Assignment: PD 115 CHANNEL RD Lot 0 Type: POOL Sub Type: Job Address: Suite: Location: APPLICANT SUNDANCER POOLS Owner: NELSON FAMILY TRUST 05-14-94 Remarks: GATE CODE IS 0088 Phone: 0000000000 Inspecto/f Total Time:Requested By: NA Entered By: CHRISTINE CD Description 59 Final Pool Act Comment (TO. Associated PCRs/CVs Date 11/19/2003 10/01/2003 10/01/2003 09/30/2003 09/30/2003 09/30/2003 09/23/2003 Inspection History Description 55 Fence/Pre-Plaster 23 Gas/Test/Repairs 31 Underground/Conduit-Wiring 23 Gas/Test/Repairs 52 Underground Plumbing 53 Electric/Conduit/Wiring 51 Excav/Steel/Bonding/Fence Act Insp Comments AP PD AP JM NO RECORD CARD AP JM CO JM CO JM SEE LIST ATTACHED CO JM GATE CODE *0051 AP PD City of Carlsbad Bldg Inspection Request For: 09/30/2003 Permit# CB032297 Title: NELSON RES 64 SF GUNITE SPA Description: Inspector Assignment: PD 115 CHANNEL RD Lot 0 . Type: POOL Sub Type: Job Address: Suite: Location: APPLICANT SUNDANCER POOLS Owner: NELSON FAMILY TRUST 05-14-94 Remarks: Phone: 6198908463 Inspector: Total Time: CD Description 23 Gas/Test/Repairs 52 Underground Plumbing 53 Electric/Conduit/Wiring Act Comment Requested By: JOHN Entered By: CHRISTINE Associated PCRs/CVs Inspection History Date Description Act Insp Comments 09/23/2003 51 Excav/Steel/Bonding/Fence AP PD CITY OF CARLSBAD BUILDING DEPARTMENT DATE LOCATION PERMIT NO. (760) 602-2700 1635 FARADAY AVENUE TIME 7 FOR INSPECTION CALL (760) 602-2725\ RE-INSPECTION FEE DUE? CT Q&£>is£'(' $0 YES FOR FURTHER INFORMATION, CONTACT PHONE CODE ENFORCEMENT OFFICER ® City of Carlsbad Public Works BUILDING PLANCHECK CHECKLIST POOLS neerng BUILDING PLANCHECK NUMBER: CB BUILDING ADDRESS: f(S PROJECT DESCRIPTION: Pool ASSESSOR'S PARCEL NUMBER:Q ^ ENGINEERING DEPARTMENT APPROVAL The item you have submitted for review has been approved. The approval is based on plans, information and/or specifications provided in your submittal; therefore, any changes to these items after this date, including field modifications, must be reviewed by this office to insure continued conformance with applicable codes. Please review carefully all comments attached, as failure to corn/ply with instructions in this report can result in suspenfpiori of permit to build. By:Date: Please marked DENIAL ched report of deficiencies necessary corrections to plans or specitIsgtjQii»^Td)r compliance with applicable codes and^standards. Submit corrected plans and/or specifications to this office for review. ATTACHMENTS Grading Permit Application Grading Permit Checklist Right-of-Way Permit Application Right-of-Way Permit Submittal Checklist and Information Sheet ENGINEERING DEPT. CONTACT PERSON NAME: Kathleen M. Farmer City of Carlsbad ADDRESS: 1635 Faraday Avenue Carlsbad, CA 92009 PHONE:(760) 602-2741 1635 Faraday Avenue • Carlsbad, CA 92008-7314 • (76O) 6O2-272O « FAX (760) 602-8562 Q Q Q RD/ Q BUILDING PLANCHECK CHECKLIST - POOLS SITE PLAN 1. Provide a fully dimensioned site plan drawn to scale. Show: Lines basements — North Arrow B/£xisting & Proposed Structures Q 2. Show on site plan: ,^Drainage Patterns ""/B^Existing & Proposed Slopes ^. Existing Topography Indicate what will happen with 11 excavated from pool area Retaining Walls (location and height) Note: If excavated soil is not to be removed from property but regraded on site, show proposed elevations and slopes. If any portion of retaining walls are over 4' in height, a separate permit is required. Retaining Wall Permit CB Applied for Approved .• . •. 3. Include on title sheet: A. Site Address B. Assessor's Parcel Number C. Legal Description D. Grading Quantities Cut Fill Import/Export 4. Project does not comply with the following Engineering Conditions of approval for Project No. ' . • - Conditions were complied with by: GRADING PERMIT REQUIREMENTS Date: The conditions that invoke the need for grading permit are found in Section 1.1.06.030 of the Municipal code. 5a. Inadequate information available on Site Plan to make a determination on grading requirements. Include accurate grading quantities (cut, fill, import, export). 5b. Grading Permit required. A separate grading plan prepared by a registered Civil Engineer must be submitted together with the completed application form attached. Note: The Grading Permit must be issued and rough grading approval obtained prior to issuance of a Building Permit Page 1 of 2 2ND/ Q Q a a. • a 5c. A Grading Permit has been applied for: PE2 DWG Grading Inspector sign off by: Date: 5d. No Grading Permit required. MISCELLANEOUS PERMITS 6. A RIGHT-OF-WAY PERMIT is required to do work in City Right-of-Way and/or private work adjacent to the public Right-of-Way. A separate Right-of-Way issued by the Engineering Department is required for the following: • • Q Please complete attached Right-of-Way application form and return to the Engineering Department together with the requirements on the attached Right- of-Way checklist, at the time of resubmittal. ; Right-of-Way Permit and Pool Building Permit will be issued simultaneously. 7. Remarks , Page 3 of 3 H:\Developmenl Services\MASTERS\CHECKLISTS\Buil()inQ Plancheck Cklisl Form- POOUS.doc Rev. 8/22/96 PLANNING/ENGINEERING APPROVALS PERMIT NUMBER CB ft 3 - 2,2^7 ^7 DATE ADDRESS //•*) chonncJ RESIDENTIAL TENANT IMPROVEMENT RESIDENTIAL ADDITION MINOR «$10,000.00) PLAZA CAMINO REAL CARLSBAD COMPANY STORES VILLAGE FAIRE COMPLETE OFFICE BUILDING OTHER (.in 3 PLANNER DATE ENGINEER DATE Docs/MUforms/Planning Engineering Approvals c, r • -ST.i;o QiS'o- «.*f f! '• POLICYHOLDER COPY . . P.O. SbX 807, SAN FRANCISCO.CA 94142-0807 COMPENSATION \ , ,' \ „ , SNSURANC^ "/_-••' : '•" F-LJND CERTIFICATE OF WORKERS1 COMPENSATION INSURANCE ISSUE DATE 04-11-20O3 v -,. \ STATE CONTRACTOR'S LICENSE BOARD SD P 0 BOX- 2,6000 - SACRAMENTO CA 35826 ^, GROUP: POLICY NUMBER: O735975-2OO3 CERTIFICATE ID: 11 - - CERTIFICATE EXPIRES: O4-11-2OO4 O4-11-2OO3/O4-11-2O04 > LICENSE NUMBER: LICENSE # 482435 INCEPTION DATE: 04-11-2003 D.o,: SD This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by tlWf{ ' California insurance Commissioner to the employer named below for the policy peri This policy is not subject to cancellation by the Fund except upon 30 days' advance written notice to the employer. We will also give you 30 days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of.insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate of insurance may toe, issued or may pertain, the insurance afforded by the ~ policies described herein is subject to all the terms; exclusions and conditions of such policies. s> ' 1 «>.$ - ' f' AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,OOO,OOO.OO PER OCCURRENCE. STANDARD EXCLUSION: INDIVIDUAL EMPLOYERS AND HUSBAND AND WIFE EMPLOYERS ARE NOT ELIGIBLE FOR* BENEFITS AS EMPLOYEES UNDER THIS POLICY. ENDORSEMENT 02O65 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-11-2OO3 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. - EMPLOYER LEGAL NAME SUNDANCER POOLS 728 INSPIRATION LN ESCONDlDO CA 92025 WILLIAMS. DAVID A AND WILLIAMS. SUSAN C &—* i -trmrt uI3 < u.5" LUo: aio I