HomeMy WebLinkAbout2856 CAMINO SERBAL; ; CB022154; Permit09-30-2002
City of Carlsbad
1635 Faraday Av Carlsbad, CA 92008
Pool Permit Permit No: CB022154
Building Inspection Request Line (760) 602-2725
Job Address:
Permit Type:
Parcel No:
Valuation:
Reference #:
Project Title:
2856 CAMINO SERBAL CBAD
POOL
2552812600 Lot #: 0
$23,210.00 Construction Type: NEW
MULLOY RESIDENCE
555 SF POOL & SPA.240 SF RETAINING WALL
Applicant:
MISSION VALLEY POOLS & SPAS
8284 MIRAMAR RD
SAN DIEGO, CA 92126
619-695-2007
Status: ISSUED
Applied: 07/23/2002
Entered By: MDP
Plan Approved: 07/31/2002
Issued: 07/31/2002
Inspect Area: RB
Owner:
MULLOY PHH.LIP&CHRISTINA
2856 CAMINO SERBAL
CARLSBAD CA 92009
7497 09/30/02 0002 01 02
COP 51.20
Total Fees:$391.68 Total Payments To Date:$340.48 Balance Due:$51.20
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
$207.49
$0.00
$134.87
$0.00
$20.00
$27.00
$2.32
$0.00
$0.00
$0.00
$0.00
$391.68
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 vou have previously been oiven a NOTICE similar lo this, or as to which the statute of limitations has previously otherwise expired.
PERMIT APPLICATION
CITY OF CARLSBAD BUILDING DEPARTMENT
1635 Faraday Ave., Carlsbad, CA 92008
FOR OFFICE USE ONLY
PLAN CHECK NO.(
EST. VAL.fe-0
Plan Ck. Deposit
Validated By
Date
Address (include Bldg/Suite #)
,. ^ _ gs-
Assessor's Parcel Existing Use Proposed Use
Description of Work SO. FT.#of Stories # of Bedrooms # of Bathrooms
3f--«<Mtmer PERSON {If (Hfferant fro/n applicant)
CL-JOQCf0 tlAdO v£
Name * Address
a.-^APPUCANT tSDContraotor D Agent for Contractor
V « <•*£/" "• ^^ ** " ' ~ '\ "VJtQov
City
D Agent for Owner
State/Zip Telephone #Fax #
State/Zip Telephone #Name
6. 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
option. Any violation of Section 7031 .6Jjy any applicant for a-permit subjects the applicant ta a civil penalty of nqtmore than five hundred dollars [
' "
6Jjy any applicant for a-permiiREVS faMul.Address "
License Class
City State/Zip
City Business License #
Telephonefzcxffisf
Address City State/Zip TelephoneDesigner Name
State License #
9. WORKERS'COMPENSATION
Workers' Compensation Declaration: I hereby affirm under penalty of perjury one of the following declarations:
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.
S3 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 carrier and oolicy number are: /^O^f
Insurance Company**-***?. Go/lO OT NfetJVogK. Policy No. l^EC ' QG24 (01-3 Expiration Date*VV^3
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS 1*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 coverue' is unlawful, and shall subject an employer to criminal penalties and civil fines up to one hundred
thousand dollar* ($igtfpOO). !• addition to th**(£>st of compensation, damages as provided for in Section 3706 of theJLabor code, interest and attorney's fees.
SIGNATURE ff^^ I , ». C ^S*~toj£./L] DATE \ "^3^ C/2-
7, OWNER-BUILDER DECLARATION jf ~7
I hereby affirm that I am exempt from the Contractor's License^Law for the following reason:
Q 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).
Q 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).
Cl 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
i^^limii/^Ki^^^^^^m^mim^»<atvt ' •
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 O NO
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district? f~l YES Q NO
Is the facility to be constructed within 1,000 feet of the outer boundary of a school site? [U 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
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
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 gfesuch permit or if the building or work authorized by such permit is suspended or abandoned
at any time after the work is commented for.a period ofjaCPdays (Seotiq{»yD6.4.4 Uniform Building Code).
tifir f ^r^ ^f~^r f
APPLICANT'S SIGNATURE S**~ _C_^ • C—-'^ j^C^ / DATE 1
'HITE: File/ YELLOW: Applicant PINK: Finance
City of Carlsbad Bldg Inspection Request
i For: 11/22/2002
Permit# CB022154
Title: MULLOY RESIDENCE
Description: 555 SF POOL & SPA,240 SF RETAINING WALL
Inspector Assignment: RB
2856 CAMINO SERBAL
Lot 0
Type: POOL Sub Type:
Job Address:
Suite:
Location:
APPLICANT MISSION VALLEY POOLS & SPAS
Owner: MULLOY PHILLIP&CHRISTINA
Remarks:
Phone: 7606327065
Inspector:
Total Time:Requested By: PHIL
Entered By: CHRISTINE
CD Description
59 Final Pool
Act Comments
Associated PCRs/CVs
Inspection History
Date Description Act Insp
11/15/2002 59 Final Pool CO RF
10/30/2002 55 Fence/Pre-Plaster AP SR
10/29/2002 55 Fence/Pre-Plaster CA RB
10/07/2002 62 Steel/Bond Beam WC PD
10/07/2002 66 Grout AP PD
10/03/2002 11 Ftg/Foundation/Piers AP PY
10/03/2002 65 Retaining Walls WC PY
10/02/2002 51 Excav/Steel/Bonding/Fence WC RB
10/02/2002 61 Footing CO RB
10/01/2002 61 Footing CO RB
09/24/2002 61 Footing DN RB
09/09/2002 21 Underground/Under Floor AP RB
09/09/2002 23 Gas/Test/Repairs AP RB
09/09/2002 31 Underground/Conduit-Wiring AP RB
08/23/2002 21 Underground/Under Floor AP RB
08/23/2002 23 Gas/Test/Repairs AP RB
08/23/2002 51 Excav/Steel/Bonding/Fence AP RB
08/20/2002 51 Excav/Steel/Bonding/Fence CA RB
08/15/2002 51 Excav/Steel/Bonding/Fence CA RB
Comments
NEEDS TO RECONNECT GRD WIRE ON THE POOL BY THE
SLIDE/NEED TO CHECK THIS AT FINAL
GROUT/WALL BY SPA
SEE NOTICE
SEE NOITICE
NEED PERMIT FOR RETAINING WALL
FOR BBQ & FIRE PIT
SEE NOTICE ATTACHED ABOUT FENCING
MAINTAIN FENCING WHEN WORKERS LEAVE
City of Carlsbad Bldg Inspection Request
For: 11/15/2002
Permit# CB022154
Title: MULLOY RESIDENCE
Description: 555 SF POOL & SPA.240 SF RETAINING WALL
Inspector Assignment: RB
2856 CAMINO SERBAL
Lot 0
Type: POOL Sub Type:
Job Address:
Suite:
Location:
APPLICANT MISSION VALLEY POOLS & SPAS
Owner: MULLOY PHILLIP&CHRISTINA
Remarks:
Phone: 8586952007 EXT 105
Inspector: ftf'
Total Time:Requested By: JESSICA
Entered By: CHRISTINE
CD Description
59 Final Pool
Act Comments
Co
Associated PCRs/CVs
Inspection History
Date Description
10/30/2002 55 Fence/Pre-Plaster
10/29/2002 55 Fence/Pre-Plaster
10/07/2002 62 Steel/Bond Beam
10/07/2002 66 Grout
10/03/2002 11 Ftg/Foundation/Piers
10/03/2002 65 Retaining Walls
10/02/2002 51 Excav/Steel/Bonding/Fence
10/02/2002 61 Footing
10/01/2002 61 Footing
09/24/2002 61 Footing
09/09/2002 21 Underground/Under Floor
09/09/2002 23 Gas/Test/Repairs
09/09/2002 31 Underground/Conduit-Wiring
08/23/2002 21 Underground/Under Floor
08/23/2002 23 GasHest/Repairs
08/23/2002 51 Excav/Steel/Bonding/Fence
08/20/2002 51 Excav/Steel/Bonding/Fence
08/15/2002 51 Excav/Steel/Bonding/Fence
Act
AP
CA
we
AP
AP
we
we
CO
CO
DN
AP
AP
AP
AP
AP
AP
CA
CA
Insp
SR
RB
PD
PD
PY
PY
RB
RB
RB
RB
RB
RB
RB
RB
RB
RB
RB
RB
Comments
NEEDS TO RECONNECT GRD WIRE ON THE POOL BY THE
SLIDE/NEED TO CHECK THIS AT FINAL
GROUT/WALL BY SPA
SEE NOTICE
SEE NOITICE
NEED PERMIT FOR RETAINING WALL
FOR BBQ & FIRE PIT
SEE NOTICE ATTACHED ABOUT FENCING
MAINTAIN FENCING WHEN WORKERS LEAVE
NOTICECITY OF CARLSBAD (760) 602-2700
BUILDING DEPARTMENT 1635 FARADAY AVENUE
DATE ~~ TIME
LOCATION
PERMIT NO.
// /v>/'.? 4 e A c //v** f
QGCK
/a
'
FOR INSPECTION CALL (760) 602-2725. RE-INSPECTION FEE DUE?
FOBJFURTHER
YES
PHONE
'<^""' ""~^r_^BUILDING INSPECTOR CODE ENFORCEMENT OFFICER
City of Carlsbad Bldg Inspection Request
For: 10/02/2002
Permit# CB022154
Title: MULLOY RESIDENCE
Description: 555 SF POOL & SPA.240 SF RETAINING WALL
Inspector Assignment: RB
2856 CAMINO SERBAL
Lot 0
Type: POOL Sub Type:
Job Address:
Suite:
Location:
APPLICANT MISSION VALLEY POOLS & SPAS
Owner: MULLOY PHILLIP&CHRISTINA
Remarks*
Phone: 8586952007 EX 105
Inspector:
Total Time:Requested By: JESSICA
Entered By: CHRISTINE
CD Description Act Comments
51 Excav/Steel/Bonding/Fence
Associated PCRs/CVs
Insoection History
Date
09/24/2002
09/09/2002
09/09/2002
09/09/2002
08/23/2002
08/23/2002
08/23/2002
08/20/2002
08/15/2002
Description
61 Footing
21 Underground/Under Floor
23 GasfTest/Repairs
31 Underground/Conduit-Wiring
21 Underground/Under Floor
23 Gas/Test/Repairs
51 Excav/Steel/Bonding/Fence
51 Excav/Steel/Bonding/Fence
51 Excav/Steel/Bonding/Fence
Act
DN
AP
AP
AP
AP
AP
AP
CA
CA
lns|
RB
RB
RB
RB
RB
RB
RB
RB
RB
Comments
NEED PERMIT FOR RETAINING WALL
FOR BBQ & FIRE PIT
SEE NOTICE ATTACHED ABOUT FENCING
MAINTAIN FENCING WHEN WORKERS LEAVE
CITY OF CARLSBAD
BUILDING DEPARTMENT
DATE
LOCATION
PERMIT NO.
NOTICE (760) 602-2700
1635 FARADAY AVENUE
5.y v$V**^ &fa
L
FOR INSPECTION CALL (760) 602-2725. RE-INSPECTION FEE DUE?
FOR FURTHER INFORMATION, CONTACT
YES
"iuiLDIlfc INSPPCT
PHONE
CODE ENFORCEMENT OFFICER
City of Carlsbad Bldg Inspection Request
For: 09/09/2002
Permit# CB022154
Title: MULLOY RESIDENCE
Description: 555 SF POOL AND SPA
Inspector Assignment: RB
2856 CAMINO SERBAL
Lot 0
Type: POOL Sub Type:
Job Address:
Suite:
Location:
APPLICANT MISSION VALLEY POOLS & SPAS
Owner: MULLOY PHILLIP&CHRISTINA
Remarks:
Phone: 8586952007
Inspector:
Total Time:
CD Description Act Comments
31 Underground/Conduit-Wiring
Requested By: CRYSTAL
Entered By: GIOVANNA
Associated PCRs/cVs
Inspection History
Date Description Act Insp Comments
08/23/2002 21 Underground/Under Floor AP RB
08/23/2002 23 Gas/Test/Repairs
08/23/2002 51 Excav/Steel/Bonding/Fence
08/20/2002 51 Excav/Steel/Bonding/Fence
08/15/2002 51 Excav/Steel/Bonding/Fence
AP RB
AP RB MAINTAIN FENCING WHEN WORKERS LEAVE
CA RB
CA RB
f •»
CITY OF CARLSBAD
BUILDING DEPARTMENT
DATE
NOTICE (760) 602-2700
1635 FARADAY AVENUE
LOCATION.
PERMIT NO.
TIME
et^c i
~s 0*0tJ
FOR INSPECTION CALL (760) 602-2725. RE-INSPECTION FEE DUE?
FOR FURTHER INFORMATION, CONTACT
YES
BUILI
PHONE
CODE ENFORCEMENT OFFICER
City of Carlsbad
Public Works — Engineering
BUILDING PLANCHECK CHECKLIST
POOLS
BUILDING PLANCHECK NUMBER: CB
BUILDING ADDRESS:
PROJECT DESCRIPTION: Pool
ASSESSOR'S PARCEL NUMBER:
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 comply with instructions in this
result ^suspension of pejmit to bu
^^ ( > f/
Date:
DENIAL
Please see the attached report of deficiencies
marked with D. Make necessary corrections to
plans or specifications for compliance with
applicable codes and standards. Submit corrected
plans and/or specifications to this office for review.
By:
By:
By:
Date:
Date:
Date:
ATTACHMENTS
D Grading Permit Application
D Grading Permit Checklist
D Right-of-Way Permit Application
D Right-of-Way Permit Submittal
Checklist and Information Sheet
ENGINEERING DEPT. CONTACT PERSON
NAME: Karen Saul
City of Carlsbad
ADDRESS: 1635 Faraday Avenue
Carlsbad, CA 92008
PHONE:(760) 602-2775
H:\Devetopment SwvtauVMASTERSVFORMS -^CHECKLISTS -\BUILDING PLANCHECK CKLIST FORM - POOLS.toc
Rev.W22fl»
1635 Faraday Avenue • Carlsbad, CA 92008-7314 • (76O) 6O2-272O • FAX (76O) 602-8562
?
BUILDING PLANCHECK CHECKLIST - POOLS
SITE PLAN
2NDvr s*07
Q Q 1 . Provide a fully dimensioned site plan drawn to scale. Show:
North Arrow J Property Lines
. Existing & Proposed Structures /o. Easements
2. Show on site plan:
AP Drainage Patterns BC Indicate what will happen with
jeL. Existing & Proposed Slopes _/SO1' excavated from pool area
X?T Existing Topography &. Retaining Walls
(location and height)
Note: If excavated so// 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:
ay. Site Address
p. Assessor's Parcel Number
j& Legal Description
D. Gjgdjng Quantities Cut Fill Import/Export
! grading is not required, write "No Grading" on plot plan.
Q Q Q 4. Project does not comply with the following Engineering Conditions of approval
for Project No.
Conditions were complied with by: Date:
GRADING PERMIT REQUIREMENTS
The conditions that invoke the need for grading permit are found in Section 11.06.030
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 2 of 3
H:\Devetopment S«vin>\MASTERS\CHECKI.ISTS\Bulkjing Planctwck Ckltet Form- POOLS.doc Rev. 8/22/96
Q Q Q 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:
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:\Devetopmenl ServtaM\MASTERS«>CCKUSTS\BuikJlng Plandwck CUM Form- POOLS.doc
•\ACORDm
PRODUCER . •
Wateridge Insurance Services
10525 Vista Sorrento Pkwy #300
San Diego CA 92121
Michael S. Galloway
Phone NO. 858-452-2200 FaxNo. 858-452-6004
INSURED
:•:•:•:•:•:•:•:DATE (MM/DO/YY) X
06/28/02 ::
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANYA INSCORP-Ins. Corp. of New York
COMPANY
Mission Valley Pools & Spas,
8284 Miramar Rd
San Diego CA 92126
COMPANY
C
COMPANY
D
:fiG#ElWGeS:::::::::x::::::::o::::::::::::x
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
COLTR
.1.
M
A
TYPE OF INSURANCE
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
X;X | CLAIMS MADE [ X [ OCCUR
OWNER'S 4 CONTRACTOR'S PROT
t
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
GARAGE LIABILITY
EXCESS LIABILITY
UMBRELLA FORM \
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
THE PROPRIETOR/ ,NC,
OFFICERS ARE: X EXCL
OTHER
POLICY NUMBER
CAIC10021625
POLICY EFFECTIVE
DATE (MM/DD/YY)
06/26/02
POLICY EXPIRATION
DATE (MM/DD/YY)
06/26/03
LIMITS
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGO
PERSONAL & ADV INJURY
EACH OCCURRENCE
FIRE DAMAGE (Any one lire)
MED EXP (Any one person)
COMBINED SINGLE LIMIT
BODILY INJURY(Per person)
BODILY INJURY(Per accident)
PROPERTY DAMAGE
AUTO ONLY - EA ACCIDENT
EACH ACCIDENT
AGGREGATE
EACH OCCURRENCE
AGGREGATE
X I WC STATU-1 TORY LIMITS OTH-ER
EL EACH ACCIDENT
EL DISEASE - POLICY LIMIT
EL DISEASE - EA EMPLOYEE
S
S
S
$
$
$
S
$
S
$
t
S
S • """-si
S
** .-.
si, 000, 000
si, 000, 000
si, 000, 000
DESCRIPTION OF OPERATIONS/UOCATIONS/VEHICLES/SPECIAL ITEMS
*10 DAY NOTICE IF CANCELLED FOR NON-PAYMENT OF PREMIUMRE: ALL OPERATIONS OF THE NAMED INSURED.
:CeRTCFlCAT£HQtbE;R-:-:x:x:x
DIME004 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
DIMENSIONS IN WATER
1967 WILBUR AVENUE
SAN DIEGO CA 92109
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KINDJJfON JHE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED^ijBgSESurfrt'E^^ 4 jf
ACQRpiS^Sjfi/^jXxXxXxXxXv
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