HomeMy WebLinkAbout2041 CORDOBA PL; ; CB013433; PermitCJI
15-06-2001
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 CB013433
Building Inspection Request Line (760) 602-2725
2041 CORDOBA PL CBAD
RESDNTL Sub Type
2073007600 Lot #
$8,446 00 Construction Type
Reference #
0 Structure Type
0 Bathrooms
BOWER - KITCHEN REMODEL
RAD 82 SF
RAD
0
NEW
Status
Applied
Entered By
Plan Approved
Issued
Inspect Area
Orig PC#
Plan Check#
ISSUED
11/05/2001
JM
12/06/2001
12/06/2001
Applicant
WORTHING INC, B A
690 CARLSBAD VILLAGE DR
CARLSBAD, CA 92008
619-729-3965
Owner
BOWER JEROME L&MARY $02 12/06/01 0002 01
CGP
2041 CORDOBA PL
CARLSBAD CA 92008
02
177-49
Total Fees $237 28 Total Payments To Date $5979 Balance Due $17749
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
Pot Water Con Fee
Meter Size
Add'l Pot Water Con Fee
Reel Water Con Fee
$91 99 Meter Size
$0 00 Add'l Reel Water Con Fee
$59 79 Meter Fee
$0 00 SDCWA Fee
$0 00 CFD Payoff Fee
$1 00 PFF
$0 00 PFF (CFD Fund)
$0 00 License Tax
$0 00 License Tax (CFD Fund)
$0 00 Traffic Impact Fee
$0 00 Traffic Impact (CFD Fund)
$0 00 Sidewalk Fee
$0 00 PLUMBING TOTAL
$0 00 ELECTRICAL TOTAL
$000 MECHANICAL TOTAL
$0 00 Housing Impact Fee
$0 00 Housing InLieu Fee
Master Drainage Fee
$0 00 Sewer Fee
$0 00 Additional Fees
TOTAL PERMIT FEES
$000
$000
$000
$000
$000
$000
$000
$000
$000
$000
$000
$3400
$2000
$3050
$000
$000
$000
$000
$000
$237 28
PERMIT APPLICATION
CITY OF CARLSBAD BUILDING DEPARTMENT
1635 Faraday Ave , Carlsbad, CA 92008
i PRO JECf "INFORMATION ?j, •«•"
FOR OFFICE USE ONLY
PLAN CHECK NO
EST VAL
Plan Ck Deposit
Validated By
Date Af/5//l/
Address (include Bldg/Suite #)Business Name (at this address)
Legal Description Lot No Subdivision Name/Number Unit No Phase No Total # of units
11 ''YiTil flflfl? 'M •-."
Assessor s ParceL*-2.cn-Existing Use Proposed Use CGP =>9 79
Description of Wor SQ FT #of Stories # of Bedrooms # of Bathrooms
2 CONTACT PERSON Of different from applicant)
"J 4ftrV\f?
Name
3 APPLICANT,Contractor
Address City
or Contractor -*|H|: Owner! D^Agent for Owner ;tractor -slgJ.Owneni LJ'fogSrirai
Name
4 PROPERTY OWNER
Address City State/Zip Telephone #
Address City I State/Zip TelephoneName
S CONTRACTOR • COMPANY NAME -' jS" "•-••,
(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 »f/6ection 7031 5 by anvapphcant for a permit subjects, 1fie applicant to a civil pjsnalty of_not more than five hundred dollars ^$5001)
Address
License Class
"TO &>
EH City State/Zip
Business License #
Telephone #
\&V(
Address City State/Zip Telephone
6 WORKERS COMPENSATION
Workers Compensation Declaration I hereby affirm under penalty of perjury one of the following declarations
[3 I nave and wpl1 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
W 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 insurancecjjjjner and policy number are . \ XI.Q-IJ-
Insurance Company ^y\K\£. J-i^N'O-' Policy No C^ryP "' */|NI'\J U ' / / Expiration I
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS [$100] OR LESS)
C3 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 ($100006) in addjflbn to. the cost of compensation damages as provided for in Section 3706 of the Lajjor cpde interest and attorney s fees
SIGNATURE -»^^^ffffiflW\ ^ DATE I \
7 ":'f:ff OWNER BUILDERVpECLARATION
I hereby affirm that I am exempt from the 8fcnt\actor s License Law for the following reason
0 I as owner of the property or my rfmplofees 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 Cd\je_x/he 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)
H] 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)
(~| 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 O YES C]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)
PROPERTY OWNER SIGNATURE DATE
COMPLETE THIS SECTION FOR /VO/V-/?£S/DSV77/« BUILDING PERMITS ONLY jg* ji!L ^; ,„ IIN;.
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? O 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' H] YES d NO
Is the facility to be constructed within 1 000 feet of the outer boundary of a school site? L~] 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
JF CONSTRUCTION LENDING AGENCY y:f::"" ^ I'..*' nn'":
:i^': '" V,
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
g9:: APPLICANT CERTIFICATION" ^ " j f f .. 3IJ1:::: .,_i;;;i " '".. ' ";.il,../.
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 CrtV 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 comrnepe^for a Dejjed of 180 days ^Section 106 4 4 Uniform Building Code)
APPLICANT S SIGNATURE -^Wv^^VK ^ \^^ DATE
HITE File YELLOW Applicant PINK Finance
City of Carlsbad Bldg Inspection Request
For 03/21/2002
Permit# CB013433
Title BOWER - KITCHEN REMODEL
Description RAD 82 SF
Inspector Assignment PD
Sub Type RAD
2041 CORDOBA PL
Lot
Type RESDNTL
Job Address
Suite
Location
APPLICANT WORTHING INC, B A
Owner BOWER JEROME L&MARY S
Remarks
Phone 7607293965
Inspect
Total Time
CD Description
19 Final Structural
29 Final Plumbing
39 Final Electrical
49 Final Mechanical
Requested By GAYLE
Entered By CHRISTINE
Act Comments
Associated PCRs
Inspection History
Date Description Act Insp
01/24/2002 17 Interior Lath/Drywall AP PD
01/24/2002 18 Exterior Lath/Drywall AP PD
01/18/2002 16 Insulation AP PD
01/18/2002 84 Rough Combo AP PD
01/17/2002 16 Insulation CA PD
01/17/2002 84 Rough Combo CA PD
01/16/2002 16 Insulation CA PD
01/16/2002 84 Rough Combo CA PD
01/15/2002 16 Insulation CA PD
01/10/2002 84 Rough Combo CO PD
12/28/2001 15 Roof/Reroof AP PD
12/28/2001 39 Final Electrical AP PD
12/18/2001 11 Ftg/Foundation/Piers AP PD
12/17/2001 11 Ftg/Foundation/Piers NR PD
Comments
SEE NOTICE ATTACHED
City of Carlsbad Bldg Inspection Request
For 01/10/2002
Permit# CB013433
Title BOWER - KITCHEN REMODEL
Description RAD 82 SF
Inspector Assignment PD
2041 CORDOBA PL
Lot
Type RESDNTL Sub Type RAD
Job Address
Suite
Location
APPLICANT WORTHING INC, B A
Owner BOWER JEROME L&MARY S
Remarks
Phone 760 65
Inspect
Total Time Requested By TERESA
Entered By CHRISTINE
CD Description Act Comments
14 Frame/Steel/Boltmg/Weldmg _
24 Rough/Topout
34 Rough Electric
44 Rough/Ducts/Dampers
Associated PCRs
Inspection History
Date Description Act Insp Comments
12/28/2001 15Roof/Reroof AP PD
12/28/2001 39 Final Electrical AP PD
12/18/2001 11 Ftg/Foundation/Piers AP PD
12/17/2001 11 Ftg/Foundation/Piers NR PD
NOTICE
CITY OF CARLSBAD (760) 602-2700
BUILDING DEPARTMENT 1635 FARADAY AVENUE
DATE I I O ~ O
LOCATION.
PERMIT NO
fi) triiPC tltT C&eJtJ
•r
-To
B £C/lr/*h . tb
FOR INSPECT,ION/CALL (760) 602 2725 RE INSPECTION FEE DUE1? ! _ , YES
FOR FURTHER INEORMAJ4ON, CONTACTER INEORMAJ4
V L- ( t^
- 27^
PHONE
BUILDING INSPECTOR CODE ENFORCEMENT OFFICER
®
EsGil Corporation
In Partnership wild government for 'Building Safety
DATE December 05, 2001
JURISDICTION Carlsbad a PLAN REVIEWER
a FILE
PLAN CHECK NO 01-3433 SET II
PROJECT ADDRESS 2041 Cordoba Place
PROJECT NAME Addition & Remodel - Enlarge Kitchen by Adding Nook Area -
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 & checked by building department staff
The plans transmitted herewith have significant deficiencies identified on the enclosed checklist
and should be corrected and resubmitted for a complete recheck
The checklist 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 checklist is enclosed for the jurisdiction to forward to the applicant
contact person
The applicant's copy of the checklist has been sent to
Esgil Corporation staff did not advise the applicant that the plan check has been completed
Esgil Corporation staff did advise the applicant that the plan check has been completed
Person contacted Telephone #
Date contacted (by ) Fax #
Mail Telephone Fax In Person
REMARKS 1) The City to place their "soil's notice" stamp on final set of plans being approved
2) Please include "red" marked items on second or third set^f plans being approved at the city
By Tony Embuido Enclosures
Esgil Corporation
D GA D MB D EJ D PC 11/27/01 ^ trnsmtldot
9320 Chesapeake Drive, Suite 208 + San Diego, California 92123 + (858)560-1468 4 Fax (858) 560-1576
EsGil Corporation
In (Partners/tip with government for 'BuiUing Safety
DATE November 16, 2001
JURISDICTION Carlsbad
PLAN CHECK NO 01-3433 SET I
PROJECT ADDRESS 2041 Cordoba Place
PROJECT NAME Addition & Remodel - Enlarge Kitchen by adding nook area
JURJS^
a PLAN REVIEWER
a FILE
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
The applicant's copy of the check list has been sent to
Brooks Worthing
P O Box 1041, Carlsbad, CA 92008
Esgil Corporation staff did not advise the applicant that the plan check has been completed
Esgil Corporation staff did advise the applicant that the plan check has been completed
Person contacted Brooks Worthing
Date contacted M/XT/OI (by fry)
Mail ^^Telephone Fax <^ In Person
REMARKS
By Tony Embuido
Esgil Corporation
D GA D MB D EJ PC
Telephone # 760-729-9674 39(^5
Fax # (l^o) 12?
Enclosures
11/06/01 trnsmtldot
9320 Chesapeake Drive, Suite 208 + San Diego, California 92123 + (858)560-1468 + Fax (858) 560-1576
Carlsbad O1-3433
November 16, 2001
GENERAL PLAN CORRECTION LIST
JURISDICTION Carlsbad
PROJECT ADDRESS 2041 Cordoba Place
DATE PLAN RECEIVED BY
ESGIL CORPORATION 11/06/01
REVIEWED BY Tony Embuido
PLAN CHECK NO 01-3433
DATE REVIEW COMPLETED
November 16, 2001
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 disabled access This plan review is
based on regulations enforced by the Building Department You may have other corrections
based on laws and ordinances enforced by the Planning Department, Engineering Department
or other departments
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
• Please make all corrections on the original tracings and submit two new complete sets of
prints to ESGIL CORPORATION
• To facilitate recheckmg, please identify, next to each item, the sheet of the plans upon
which each correction on this sheet has been made and return this sheet with the
revised plans
• 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 on the plans Have changes been made not resulting from this list?
Yes a No
Carlsbad 01-3433
November 16, 2001
• PLANS
• Please make all corrections on the original tracings, as requested in the correction list
Submit (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 For room additions, show compliance with the energy standards See attached
a) Glazing exceeds 20% of the total area served Please prove otherwise See
attached
b) Note on the plans "The manufactured windows shall have a label attached
certified by the National Fenestration Rating Council (NFRC) and showing
compliance with the energy calculations "
2 Specify GFCI for any new outlets being installed or replaced at the kitchen counters
See floor plan
3 The City (upon final transmittal) to place their "soils notice" stamp on the plans
4 Indicate floor area of addition on site and/or floor plan
5 All sheets of plans must be signed by the person responsible for their preparation
(California Business and Professions Code)
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 Tony Embuido at Esgil Corporation Thank you
2001 Building Energy Standards Page 1 3 9
TABLE 1-Z7— ALTERNATIVE COMPONENT PACKAGES FOR
CLLMATE ZONE 7
COMPONENT
BUILDING ENVELOPE
Insulation mimmums2
Ceiling
Wood-frame walls
"Heavy mass" walls
"Light mass" walls
Below-grade walls
Slab floor perimeter
Raised floors
Concrete raised floors
Radiant Barrier
GLAZING
Maximum U \aliu? Factor3
Maximum total area
SOLAR HEAT GAIN COEFFICIENT*
South-facing glazing
West-facing glazing
East-facing glazing
North-facing glazing
THERMAL MASS3
jvcir jp ATrrw rOvTPOr
SPACE-HEATING SYSTEM6
Electric-resistant allowed
If oac AFT IF —
ii neat pump, spilt system tiorr
Single package system HSPF
SPACE-COOLING SYSTEM
If cnlit Evctf»m A/P QFFR —
Thermostatic expansion valve
If single package A/C, SEER =
SPACE CONDITIONING DUCTS
Duct sealing
DOMESTIC WATER-HEATING TYPE
System must meet budget, see
Section 151 (b) 1 and (f) 98
PACKAGE '
4-
TJ 10
p n
rpi i"\O1 ')rp i m|K 1 UJ
v^ ^
vp
P R
\T ^
1 10
v p
9 6no
6 1°o
\R
\ p
\R
v P-
PFOTI.CV
v P
x R
\n
-1^0
f, q
f. f.
\r\ o
9 7
\nvVI1J
&
P ift
pn
fP 1 -'Hli^i \)
rp^ si[1O JJ
XT A
p-7
pn
XT A
0 fn
1 -\n\
>TP
xm
Vtp
>TP
>TP
xrp
XTR
•\TD
•\rp
xrn
•700 /
b S
A (S
10 0
9 ^
^n•^UlJ
c1
R38
R21
NA
NA
NA
R7
R21
NA
NR
050
14%
~\TT>
x-p
Nft040
NR040
NR040
NR040
REO
vp
vp
Yes7
78%
68
66
100
NR
97
REO
Any9
D
R30
R13
(R244)
NA
RO
NR
R192
RO
NR
075_
^^20°/oJ^4Sr
NR040
NR040
NR-040
NR040
NR
NR
N£
No
MIN
MIN
MIN
MIN
NR
MJN
REO*
Any
*As an alternative under Package D, alazina with a maximum 0 40 U- factor and maximum 0 35
Solai Heat Gain Coefficient can be substituted for duct sealing All other requirements of Packase D
must be met
Legend
NR = Not Required
REQ = Required
See notes following Table 1-Z16
NA = Not Applicable
MIN = Minimum
Carlsbad 01-3433
November 16, 2001
VALUATION AND PLAN CHECK FEE
JURISDICTION Carlsbad
PREPARED BY Tony Embuido
BUILDING ADDRESS 2041 Cordoba Place
BUILDING OCCUPANCY R-3
PLAN CHECK NO 01-3433
DATE November 16, 2001
TYPE OF CONSTRUCTION V-N
BUILDING
PORTION
Addition-Per City
Air Conditioning
Fire Sprinklers
TOTAL VALUE
Jurisdiction Code
AREA
(Sq Ft)
82
CB
Bldg Permit Fee by Ordinance ^
Valuation
Multiplier
By Ordinance
Reg
Mod
VALUE ($)
8,446
8,446
$91 99
Plan Check Fee by Ordinance
Type of Review
Repetitive Fee
Repeats
0 Complete Review
D Other
,—i Hourly
Structural Only
Hour*
Esgil Plan Review Fee
$5979
$5151
Comments
Sheet 1 of 1
macvalue doc
PLANNING/ENGINEERING APPROVALS
PERMIT NUMBER CB DATE
ADDRESS
TENANT IMPROVEMENT
RESIDENTIAL ADDITION MINOR
« $10,000.00)
PLAZA CAMINO REAL
CARLSBAD COMPANY STORES
VILLAGE FAIRE
COMPLETE OFFICE BUILDING
OTHER
PLANNER DATE
ENGINEER
V
DATE
Docs/Misforms/Planning Engineering Approvals
COMPENSATION
IN SURANCE
PO BOX'd07, SAN FRANCISCO,CA 94J Oj-0807^V;^"^'"-'* ^-UT^V-^ •#£
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
r^-r* • :,y-^ _w;, '
'
ISSUE DATE 01-01-01
CITY OF CARLSBAD
ATTN- BUILDING DEPARTMENT
2075 LAS PALMAS DRIVE
CARLSBAD CA 92009-^*859
POLICY NUMBER: 046-01 UNIT 0008775
CERTIFICATE EXPIRES 01-O1-02 .,
.JQB ALL OPERATIONS
This is to certify that we have issued a valid Workers' Compensation insurance policy in a 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 employer
We will also give you 30 days' advance notice should this policy be cancelled prior to its normal expiration
, — ^ i*"* •* *• \ '^ .., .-
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
, ..... '. ^PRESIDENT
•<" v ,. .> *• ""'
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS' $1,000,000 00 PER OCCURRENCE ' '.
*••--..-, •• : i, * ' -
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01/01/01 IS ATTACHED TO AND
FORMS A PART OF THIS POLICY
EMPLOYER LEGAL NAME
B A WORTHING INC
FO BOX 1 01* 1
CARLSBAD CA 92018
B A WORTHING INCWORTHING, INC
PRINTED 12-16-00 P0409