HomeMy WebLinkAbout2840 CACATUA ST; ; 77-7943; PermitMODEL N?.
BUILDING PERMIT APPLICATION
City of CARLSBAD, CALIFORNIA 92008
Phone 729-1181 Permit No. 77 7943
I’ $9 -- SESsblM+** 5 * - *
Applicant to complete numbered spaces only.
JOB ADDR E55
PARCEL NUMBER
6
U SROi L DI N 6
NO. BORMS 4
8 Class of work: dNEW 0 ADDITION 0 ALTERATION 0 REPAIR 0 MOVE 0 REMOVE
9 Describe work:
10 Change of use from
Change of use to
11 Valuation of work: $ 7.st 70 st, r .-
SPECIAL CONDITIONS:
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICALJPLUMB- ING, HEATING, VENTILATING OR AIR CONDITIONING.
TlON AUTHORIZED IS NOT COMMENCED WITHIN 120 DAYS,OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A
MENCED.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONST-RUC-
PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COM-
SIGNATURE OF CONTRACTOR on AUTHORIZED AGENT (DATE)
SIGNATURE OF OWNER (IF OWNER BUILDER1 (DATE)
* No. of Size of Bldg.
(Total) Sq. F&% I Stories Occ. Load
Dwelling Units
PLANNING DEPT.
SOIL REPORT
ENGINEERING DEPT. I I I
WATER DEPT. I I I
r, WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
TOTAL FEES
r
7 3-79 43 tNSPECTION RECORD -, I DATE I REMARKS 1 INSPECTOR
FOUNDATIONS:
SET BACK I I I
TRENCH I REINFORCING
FOUNDATION WALL &
..lP*-r..*C. -C.fi*r...II
TIME:
INSPECTOR PERMIT NO.
OWNER
BUILDING
0 FOUNDATION
0 REINFORCING STEEL
0 MASONRY
0 GROUT - GUNlTE
0 FLOOR AND CEILING FRAME
c] SHEATHING
0 FRAME
0 EXTERIOR LATH
0 INSULATION
0 INTERIORLATH OR DRYWALL ?d FINAL
0 UNDERGROUND PLUMBING
0 UNDERGROUND WATER
-
READ
0 ROUGH PLUMBING In
0
0
0
0
0
0
YF
TOP OUT PLUMBING
SEWER AND PL/CO
TUB OR SHOWER PAN
GAS TEST
E L ECT R IC A L
0 TEMPORARY SERVICE
0 ELECTRIC UNDERGROUND
0 ROUGH ELECTRIC
0 POOL BONDING
0 ELECTRIC SERVICE
0 CEILING HEAT
c3. G.F.I.
0 SMOKE DETECTOR
0 FINAL
I MISCELLANEOUS
WATER HEATER
FINAL
OR INSPECTION: 0
0 A.M.
0 P.M.
0 PLENUM AND DUCTS
0 COMBUSTION AIR
0 PATIO
0 SIGN
0 GRADING
0 DRIVEWAY
0 CONDITIONED AIR SYST
0 REFER PIPING
0 FINAL
I WEDNESDAY THURSDAY 3
'EMS
0 FRIDAY
SPECIAL INSTRUCTIONS
Y
PERSON TAKING REPORT
REQUESTED BY
PLUMBING PERMIT APPLICATION
APPLICATION AND KNOW THE SAME TO BE TRUE AN0 CORRECT. ALL PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVk AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
City of CARLSBAD, CALIFORNIA 92008
Phone 729-1181 bplicant to complete numbered spaces only. Perm it No. 7 7-4iiYJp I JOS ADOILIS
WATER PIPING L TREATING EQUIP.
WASTE INTERCEPTOR
VACUUM BREAKERS
LAWN SPRINKLER SYSTEM
.
COMP ENS A T ION IN S.J 4R Rpe WAIL ADDICSS
I
18 Chef work: HNEW AOOlTlON 0 ALTERATION 0 REPAIR I
8 Oacribrwork:
PERMIT FEES
I PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COM- I 1 SLOPSINK Ill I 4. I ,434 - GAS SYSTEMS: NO. OUTLETS
, CESSPOOL 1
XPTiC TANK & PIT
ROOF DRAINS
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. . CASH
., 3
......... .. i ............ ..+ .....
INSPECTOR
ELECTRICAL PERMIT APPLICATION
LOT NO. BLK. I E::k. TRACT (OSEE ATTACHED SHEET)
ENGINEER MAIL ADDRESS PHONE LICENSE NO.
b
BRANCH TES?C COMPENSATION INS CARRIER * clisllan eo, ,4 7 f-
USE OF BUILDING
’rjkyl;leFsmily~
I Class of work: a NEW 0 ADDITION ALTERATION 0 REPAIR
I Dewibework: nrwwd wf~ins
c
PERMIT-=
PECIAL CONDITIONS:
I P
WPLICATION ACCEPTEO BY I PUNS CHECKED BY I APPROVED/O@ISUANCE BV
NOTICE
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUC- TION AUTHORIZED IS NOT COMMENCED WITHIN 120 DAYS,OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COM
MENCED.
i
‘4, /..*/ “-7- -.
-4
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE)
SIGNATURE OF OWNER (IF OWNER BUILDER) (DATE)
SWIMMING POOL WIRING,
NO INCREASE IN SERVICE
NEW CONSTRUCTION, FOR EACH
AMPERES OF MAIN SERVICE, SWITCH,
FUSE OR BREAKER
NEW SERVICE ON EXISTING BLDG. FOR EA. AMPERE OF INCREASE IN MAIN SERVICE. SWITCH. FUSE OR BREAKER
REMODEL, ALTERATION, NO CHANGE
IN SERVICE, FOR EA. AMPERE OF
IN CR EASE
TEMP. SERVICE UP TO AND INCLUD- ING 200 AMP.
TEMP. SERVICE OVER 200 AMP. PER 100
ISSUANCE FEE
TOTAL FEES
100
-
Each -
25
I
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
PLAN CHECK VALIDATION CK. M.O. CASU PERMIT VALIDATION CK. M.O. CASU
INSPECTOR
MECHANICAL PERMIT APPLlC4<OM--- * :.
~ ..,rd,,g
Permit No. 75%
City of CARLSBAD, CALIFORNIA 92008
Phone 7 29-1 181 Applicant to complete numbered spaces only, r Jon ADDR Ess /41 I
LOT NO. DLU LCCAL 1 DCSCR.
TRACT (OSEE ATTACMED SHEET1
- CONTRACTOR_ I MAIL ADD ESS - PHONE CITY LIC. NO. STATE LIC. NO.
*
SPECIAL CONDITIONS:
-,
LICENSE NO.
Typeof Fuel: Oil 0 Nat. Gas Cr"LPG. 0
PERMIT FEES
No. Type of Equipment Fee
Air Cod. Units-H.P. Ea. $1
Refrberation Units-H.P. Ea.
4
5
LICENSE NO. CN C IN EER MAIL AODRESS PYONE
WQYT MAIL ADDRESS IRhNCN
18 Class of work: WW 0 ADDITION 0 ALTERATION 0 REPAIR
~
9 Describe work:
I I I Boilers-H.P. Ea. II
Gas Fired A.C. Units-Tonnage Ea.
Gravitv Svstems-B.T.U. M Ea.
I Forced Air Systems-B.T.U. M Ea.
APPLICATION ACCEPTED BY PLANS CHECKED EV APPROVED FOR ISSUANCE 8V c ..
Floor F urnaces-B.T.U. M I I
Wall Heaters43.T.U. M
;?
M ,,wr. NOTICE Unit He6ten-B.T.U.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUC- TlON AUTHORIZED IS NOT COMMENCED WITHIN 120DAYS.OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A
PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COM- Ventilation Fan
Evaporative Coolers
Clothes Dryers
'
MENCED. I I RanaeHood II I Air Handling Unit- C.F.M. I I I Incinerator
I I I I I I I I I J I I I I I
TOTAL FEES
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
PLAN CHECK VALIDATION CK. M.O. cnsH PERMIT VALIDATION CK. M.O. CASH
INSPECTOR
CORRECTION LIST CITY OF CARLSBAD
BUILDING DEPARTMENT
SINGLE FAMILY AND MULTIPLE FAMILY RESIDENTIAL PLAN
/ f ..- (714) 729-1181
*WARNING: PLAN CHECK FEES: Where no action is taken by the applicant in 120 days,
and no building permit is
.y:
Job Address: 2 e40 (!?Amha Owner
Contractor: \ Engineer
Occupancy . Type of Construction Valuation
Basic allowable bldg. area Jst Floor 2nd Floor
Allowable Increase Due to
REQUIRED PL \
3. Floor Plan 8. Roof Plan
4. General Framing 9. Index Sheet
5. Foundation Details
TO THE APPLICANT
A. Correct Plans where corrections has been circled. Flag
Corrections.
B. Incomplete, Indefinite or Faded Drawings or Calcu-
lations not acceptable.
C. Required Engineer’s or Surveyor’s Calculations or
Plans shall be signed in ink.
D. Reverse Plans may not be used. Provide correct Plot
Plan, Foundation Plan, Floor Plan and Elevations.
E. The approval of plans and specifications does not
permit the violation of any section of the Building
Code‘or other City, County or State Law.
4th Floor
24. Indicate clearance from grade to bottom of floor joists
ow pier size, spacing and depth, into undisturbed
and girders.
e girder size, spacing and direction.
all conditions of soils report on plans.
positive drainage away from footings on site
n. 5” fall in 6 feet.
29. Specify minimum 18” x 24” access opening.
30. Where expansive soils exist, planters adjacent to found-
ations are not recommended.
31. Specify underfloor ventilation equal to 2 square feet
for each 25 lineal feet of foundation plus one opening
within 3’ of each corner.
32. Step footings when slope exceeds 1 : 10.
FRAMING
33. Provide typical framing details.
34. Specify all lumber grades.
35. Specify fire blocking at floor, ceiling cove and mid-
height of walls over 10’ in height.
36. Show diagonal bracing at each corner and every 25
feet of wall.
38. Show size, direction and spacing of floor joists in
39. Double floor joists or
GENERAL
1. Submit fully dimensioned Plot Plan, drawn to scale, 37. Clarify bracing of wall.
are overspanned.
including all easements on property.
2. Show all existing and proposed buildings on Plot Plan.
3. Show correct legal description on Plan.
4. Show all Off Site Improvements, Driveway Approach, beam under parallel partitions.
Light Standards, Fire Hydrants, Water Meters, Sub size for openings over 4’. Show double Structures, Trees, etc.
ceiling joists and rafters are
spacing and direction.
rect Lot Dimensions.
w existing and finish contour lines.&
icate all grading to be done.
icate Elevations of Garage Floor, and Street and
eY - ‘ . )’Wk+hA -td 4’0.C.
44. Show purlins on edge and indicate size. Same size as
rafters minimum.
10Undicate-Centerline and Edge Profile of Driveway.
11. Slope of driveway not to exceed 15%.
isposal of surface water&
l3aSan Diego County Health Dept. approval required.
13bShow all requirements for handicapped. U.B.C.
13cL.C.W.D. sew < receipt required.
13dCoastal approval letter required.
14. Carry water from
Section 1711.
under sidewalk through curb into street with cast
iron pipe.
15. Provide engineering calculations for
ovide engineer’s moisture report.
ading permit required.
18. Fire Dept. approval required.
19. Specify concrete mix @ 2000 P.S.I. minimum.
20. Dimension footing sizes and clearance from grade.
21. Show depth of footings below natural or undisturbed
22. Indicate pressure treated foundation still, or equal.
23. Show foundation bolt size, spacing and penetration
grade.
into concrete. %” x 17” for masonry.
45. Brace roof framing to partitions.
46. Indicate solid sheathing and 2 x 6 or 3 x 4 studs on
first floor of three story construction. 3 47. Show section through
48. Show planter box details and water proofing, Sec.
51. Provide typical chimney details.
52. Specify 2” minimum clearance between chimney and
53. Specify post protection when bearing on concrete.
54. Provide parapet details.
56. Specify inspection class
58. Provide drip screed 2” below mud sill.
59. Indicate how required structural and fire resistive
integrity will be maintained. Where penetration will - be made for electrical, mechanical, plumbing and
communications conduits, pipes and similar systems.
Section 301 D.
2517 C7.
framing.
required for
60. Clarify dimensions at
61. Show window type, sizes and locations.
62. Light and/or ventilation inadequate in
(1/10 floor area - 12 square feet min. except bath-
room), 1 **NOTE IN MARGIN WHERE CORRECTIONS HAVE BEEN MADE
53. Provide, vertical clearance and
* horizontal clearance from range top to combustibles.
54. Indicate attic scuttle (22” x 30” min.)
55. Provide draft separation for attic area in excess of
2500 sq. ft.
66. Separate area between dropped ceiling and floor above
to 1000 sq. ft. max.
67. Specify stall shower min. width 30” minimum floor
area 900 sq. inches.
68. Specify wall finish in shower area not to be adversely
affected by moisture to 6‘ above the floor, and provide
shatterproof doors.
69. Water closet area minimum width to be 30”.
70. Show material to be used under tile.
71. Openings closer than
72. Show ceiling height.
73. Show lateral cross bracing at garage plate line.
74. Show bedroom window as exit, section 1304.
to property line shall be of hour construction.
ELEVATIONS
75. Indicate attic ventilation per section 3205 (c).
76. Show all eave overhangs and construction details.
77. Dimension chimney height above roof. (2’0” above
78. Indicate finish and natural grade to property line.
79. Show exterior wall finishes.
80. Indicate 15# felt or equal on exterior walls.
roof withing 10’0’’).
ROOF
81. Note roof pitch.
82. Indicate roofing material length & weather exposure
83. Show type, size and spacing of roof sheathing.
84. Fire retardant roof required due to location in
on wood shingles.
fire zone.
GARAGES
86. Garages not permitted to open into sleeping room.
87. Provide separation on all walls
88. Specify door/window opening
and ceilings adjacent to living quarters.
from garageharport into
STAIRWAYS AND EXITS
90. Provide handrails as required in Section 3305 (i).
92. Provide
93. Indicate maximum rise and minimum
95. Provide balcony railing at 42” minimum height. 36”
96. Provide intermediate rails @ 9” O.C. or equivalent
97. Indicate 6’ 6” minimum headroom clearance above
98. Show stairway construction details.
hour walls for stairwell.
run on stair.
O.K. for single family units.
for open type balcony & stair rails.
stairway.
100. Occupant load requires exits
101. Provide lights over stairways and public corridors.
102. Show change in floor level at doors 1” rnax. Sec.
330311.
102aShow handrail extending 6” beyond the top & bottom
risers & terminating in a post or safety terminal Sec.
3305 (i).
from
PLUMBING
103. Indicate location of water heater.
104. Show temperature and pressure relief valves on water
heaters with discharge lines to outside. Sec. 1007.
105. Water heater not to be located in bathroom or under
stairway or landing.
106. Provide square inches of ventilation at top and
bottom of water heater.
107. Show water heater on 18 inch platform.
110. Indicate material to be used and location of sewer
(If V.C.P. use flexible compression joints only.)
111. Show two way clean out in yard box with 5’ of build-
line.
ing.
ELECTRICAL
112. Provide minimum 100 Amp. service. Condos require
113. Show meter and panel location.
113aShow fire warnings systems centered over stairs.
100 Amp. panel for each unit.
Section 1310.
MECHANICAL
114. Indicate furnace size, locations & registers and return
air. (Size)
115. Indicate heating equipment in accordance with chapter
7 of Uniform Housing Code.
116. Specify heating, air conditioning and ventilating
equipment. Installations to comply with the uniform
mechanical code.
A. Access F. Ducts
B. Location G. Ladder & Light
C. Combustion Air H. Engineer’s
D. Venting Calcs for
E. Return Air Roof Loads
117. Indicate location & type of fire dampers.
ELECTRIC
1975 N.E.C.
1. Ground-fault protection required for outdoor and
2. At least one receptical shall be installed outdoors
bathroom receptacles 210-8.
garages. 210-25b
electric as shown on floor plan.
Underground service is required. Show on plans.
MISCELLANEOUS ITEMS
1,Bored holes and notching, show details as per Section
. Ft. areas of the follow
74703 4” insulation in walls (R-11)
exterior doors weatherstriped
the following note on plans:
These plans comply with the requirements of the
California noise insulation standards.
SIGNED
DATE
TITLE
F. Show details of party wall and floor system and
S.T.C. or I.C.C. rating of each.
4. Have designer sign and date plans.
CHECKED
(DATE)
RECHECKED
(DATE)
THE FOREGOING CORRECTIONS HAVE BEEN MADE AND ARE UNDERSTOOD BY THE UNDERSIGNED:
OWNER - OR HIS AUTHORIZED AGENT
\-
B
B
-
>
UILDTNG
UILDING
INTERDEPARTMENTAL INFORMATION SHEET
DEPARTMENT
ADDRESS:
PLANNING DEPARTMENT
ZONE LOT SIZE /P 1717 LOT WIDTH ff
UNITS ALLOWED / UNITS PROVIDED
PARKING SPACES REQUIRED
% COVERAGE ALLOWED
BUILDING HEIGHT ALLOWED PROVIDED
I
PROVIDED 3
---c
FRONT SETBACK:
ALLOWED
PROVIDED
INTRUSIONS 7 '$fy$()(
LANDSCAPE & IRRIGATION PLAN
SIDE SETBACK: REAR SVTBACK:
1 COMMENTS:
ENFIRONMENTAL PROTECTION REQ:
-r
n A OK TO FINAL f&!L DATE &/-?e
FIRE DEPARTMENT . SPRIIiKLING SYSTEM FIRE PROTECTION EQUIP.
FIRE ALARMS EXITS
&
* FIRE HYDRANTS LOCATION
ADDITIONAL COMMENTS
OK TO ISSUE: DATE OK TO FINAL DATE
r
ALPHA LABORATORIES, .INC.
SOIL & FOUNDATION ENGINEE-RING ' PROJELT NC): V~O~J- -
16 Nov. 1977 DA? E :
TO : Euqene Smith
3519 Catal ina
Carlsbad, Cal if. 92008
Gent 1 emen :
Ttlis is to report the results of observations and soil tests ;.crfor;r;r,d cn
15 Nov. 1977 at 2840 Cacatua, La Costadal if. Lot 495_Meado3S-.#3__
.? - for the Durpose of determining the rroisture wntent in the exst.';-; 12 :,oi .>
includd on the su:ject sitc.
Field explorations were made tc retrieve soil sarrples in t.he centpr o? !-be
building pad. Test. pits were dug tct a d+th of at least 3 fett belw finisii
grade and molsture samnles were Gbtained at intermcdiats ieveis. \.;e fnund he!
field caisture to be 24 %
A wxirnum dry density deterninzticn was perfcrrxd in accordance ::itti ASTb1 P!35?
to ascertain the optimun: moisture content of the subject coi I. The .rca:tirnuz
density was found to be - 114.5 Lbs. Cu. Ft. at 16.2 2 gigi:,Lure.
In conclusion we find the field moisture exceeds the optimum by -7t least
7% - percent which meets the minixurn requirements for presaturation of
expansive soils.
If you have any questions, please do not hesitate to contact this office.
The opportunity to be of service is sincerely appreciated.
Respectfully submitted,
ALPHA LABORATORIES, INC.
t
cc: (I) Submitted-
7895 Convoy Court - San Diego - California 92111 - 7141292-0660
LEUCADIA COUNTY WATER DISTRICT
POST OFFICE BOX 2397 LEUCADIA. CALIFORNIA 92024 753-01SS
June 20, 1977
Mr. Michael Enken 540 Saxony Road Encinitas, CA 92024
.. Dear Applicant:
adopted Resolution No. 542 which provided for the expiration of sewer permits after 30 days if a building permit had not been obtained.
On March 24, 1977 the Board of Directors of Leucadia County Water District
Therefore, your sewer permit No. 6764 dated 5/18/77 for property located at ' 2840 Cacatua Street has expired and the permit is hereby cancelled. to be held on-:
may reapply far a sewer service permit at the District office, At that time it will be necessary for you to pay the applicable connection fee.
The connection fee will be refunded to you at the Board ineeting
July 12, 1977' I .
If it is your intention to pursue a building permit for this property you
I
If you have any questions regarding this matter please contact me.
Yours very truly,
1 EUCADIA COUNTY WATER DI STRI CT- .
CC: City of Carlsbad
..
. t.
v Joan R, Geisefhart
.:
RECEIVED
JUN 2 2 1977 CITY OF CARLSBAD J
Building Dc>ar:ment
LEUCADIA COUNTY WATER DISTRICT
APPLICATION FOR SEWER SERVICE
Owner's Name: Eugene M. Smith Phone No. 729-4332
Mailing Address: 3519 Catalina
Carlsbad, CA 92008
Trnct Description: La Costa Meadows Unit #3 Lot 495
Type of Building: Single Family No. Units Connection Charge $600.00
Lateral Size: 4" 6" 8" Saddle: -
Extra footage: @$ Easement Connection
Extra depth: @$
t Amount Rec'd $ 600 .oo J HOW Paid cash
Date Paid 6/33/77
Lateral Charge
Total $600.00
The application must be signed by the owner (or his authorized representative) of the
property to be served.
application is submitted.
The total charges must be paid to the District at the time the
If a service lateral is required, it will be installed by the Leucadia County Water
District. The service lateral is that part of the sewer system that extends from the
main collection line in the street (or easement) to the point in the street (at or near
the applicant's property line) where the service lateral is connected to the applicant's
building sewer. The applicanb. is responsible for the construction, at the applicant,s
expense, of the sewer pipeline (building sewer) from the applicant's plumbing to the
point in the street (or easement) where a connection is made to the service lateral.
The connection of the applicant's building sewer to the service lateral shall be made
by the applicant at his expense.
District's specifications, rules and regulations; and IT MUST BE INSPECTED AND APPROVED
BY THE DISTRICT BEFORE THE SEWER SYSTEM MAY BE USED BY THE APPLICANT. THE APPLICANT, OR
HIS AUTHORIZED REPRESENTATIVE, MUST NOTIFY THE DISTRICT AT THE TIME INSPECTION IS DESIRED.
ANY CONNECTION MADE TO THE SERVICE LATERAL OR COLLECTION LINE WITHOUT PRIOR APPROVAL AND
INSPECTION BY THE DISTRICT WILL BE CONSIDERED INVALID AND WILL NOT BE ACKNOWLEDGED.
The connection must be made in conformity with the
After connection is complete, the property described above is subject to a monthly
sewer service charge, billed bi-monthly in advance. The rate will be governed by the
use of the property, single family, multiple dwelling or commercial.. Non-payment of
the sewer service charge is subject to a 5% penalty per month, plus disconnection if
necessary.
The undersigned hereby agrees that the above information given is correct and agrees to
. 6/23/77 7623
Date Account No.
CITY OF CARLSBAD
BUILDING DEPARTMENT
(714) 729-1 181
CERTI FlCATlON
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. If, after making this certificate, I become subject to the workers’ compensation pro- visions of the California Labor Code, I will forthwith comply with Section 3700 of the
Labor Code,
I understand that if I fail to comply with the workers‘ compensation laws, this permit
shall be deemed revoked. I further certify that if I should contract or subcontract with any person, including any
firm or company, to do all or part of the work for which this permit is issued, I shall assure compliance by that contractor or subcontractor with Section 3800 of the California Labor Code.
SIGNE
PRINT NAME AND TITLE:
JOB ADDRESS:^&
DATED: ?