HomeMy WebLinkAbout2906 AVENIDA VALERA; ; CB960956; PermitBUILDING PERMIT Permit No: CB960956
06/12/36 13.46 Project No: A9601358
Page 1 of 1 Development No :
J Job Address: 2906 AVENIDA VALERA Suite :
Permit Type: RESIDENTAL ADD/ALT
Parcel No: 216-461-11-00
Valuation: 7,614 -- Occupancy Group: Reference#: Status: ISSUED
Description: 81 SF NOOK AREA OFF KITCHEN Applied: 05/30/96
Apr/Issue: 06/12/96
Entered Ry: RMA
Appl/C>wnr : PRICE BUILDEFS INC 619-464-8144
8317 MONO LAKE DR
SAN DIEGO CA 92119
.OO
64.00
147. 110
Ext fee Data
99 * 00
64.00
1.00
164:OO
20.00 Y
7.00
27. 00
1o.uo Y 1o.no Y
20.00
N
I.
CITY OF CARLSBAD
2075 Las palmas Dr., Carlsbad, CA 92009 (619) 438-1161
..- -A. -- - ..-
PERMIT AFVLICATTON
City of Carlsbad Building Department 2lX'S Las Palaas Dr., Carlsbad, CA 92009 (6191 438-1161
E
From List 1 (see back) give code of Permit-*:
For Residential Projects Only: From List 2 (see back) give
.........................................................
Code of Structure-'I)pe:
Net -/Gain of Dwelling Units
2 PRQTECIINFORMATION
Addr=2fob or Suite No.
Nearest C ss Street
ZF90-25 Nmy &YO6 I fl 0 2 Enerlly Calcs 0 2 Structural Cab 0 2 Soils Report 1 Addressed Envelope
~. d. #OFSTORIES 1- # OF BEDROOMS # OF BATHROOMS
CITY STATE ZIP CODE DAY TELEPHONE ydR-&/qq
NAME (last name first) ADDRESS I UAG- uom UAG-
CITY STATE ZIP CODE 92 ((7 DAY TELEPHONE
STATE LIC. # 6p6/ LICENSE CkS & -2 ' CITY BUSINESS LIC. #
ADDRESS /!%z 2%- &e./+ -NAME (last name tint +/a 6. k%?- W -& CITY 4 STATE c& ZIP CODE ~Z-L?& DAY TEEPHONE 93S$$f&TA% LIC. #
8
Workers' Compensation Declaration: I hereby attirm that I have a certificate of consent to self-insure issued by the Director ot Industrial Relations, or a certificate of Workers' Compensation Insurance by an admitted insurer, or an exact copy or duplicate thereof certified by the Director of the insurer thereof filed with the Building Inspection Department (Section 3800, Lab. C).
INSURANCE COMPANY 2 POLICY NO. /3c&y-f&IRATION DATE fl/o//q 7
Certiticate ot Exemption: I certify that in the performance ot the work tor which this@ennit is issued, I shall not emplofaw person in any manner
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.).
I, as owner of the property, am exclusively contracting with licensed contractom 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
(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, commencing 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 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars [SSOO]).
0 Business and Professions Code for this reason:
SIGNATURE DATE
cop NON-RTKJENTLU BD~DING ~LY: 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?
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district?
Is the facility to be constructed within 1,000 feet of the outer boundary of a school site?
IF ANY OF THE ANSWERS ARE YES, AFINAL CERTIFICATE OF OacUpANCY MAY NOT BE Issun> AFERJULY 1,1989 UNLESS THE APPLICANT
0 YES NO
0 YES NO
0 YES 0 NO
OFFICE OF Eh4ERGENCY SJ?XVICES AND THE AIR WLLUTION CONTROL DISIRICT.
ncy tor the pertormance of the work tor which this permit is issued (Sec 30m i Civll Code].
LENDER'S NAME LENDER'S ADDRESS
1 certity that 1 have read the applicatlon and state that the above intormation is correct. 1 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 AIS0 AGREE TO SAVE INDEMNIFY AND KEEP HARMLESS THE CITYOF CARISBAD AGAINST AIL LUB- JLJJXMENTS, a)5Is AND EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID Cl" IN OONSIQUENCE OF THE GRANTING OF THIS PERMlT.
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 days from the date of such permit or if the building o menced for a period of 180 days (Section 303(d) Uni
< < CITY OF CARLSBAD
INSPECTION REQUEST
PERMIT# CB960956 FOR 08/09/96 INSPECTOR AREA DC DESCRIPTION: 81 SF NOOK AREA OFF KITCHEN PLANCK# CB960956
TYPE: RAD CONSTR. TYPE NEW
JOB ADDRESS: 2906 AVENIDA VALERA STE : LOT:
APPLICANT: PRICE BUILDERS INC PHONE: 619-464-8144
CONTRACTOR: PHONE :
OWNER: PHONE :
OCC GRP
REMARKS: MW
SPECIAL INSTRUCT:
TOTAL TIME:
CD LVL DESCRIPTION ACT COMMENTS
19 ST Final Structural
29 PL Final Plumbing
39 EL Final Electrical
49 ME Final Mechanical
***** INSPECTION HISTORY *****
DATE DESCRIPTION ACT INSP COMMENTS
071696 Interior Lath/Drywall AP DC
071696 Exterior Lath/Drywall AP DC
071296 Insulation AP DC
070396 Frame/Steel/Bolting/Welding AP DC
061896 Ftg/Foundation/Piers AP DC
EsGil Corporation
Trofessional Thn Review Engineers
DATE: 6/6/96
JURI SDl CTl ON: Carlsbad
PLAN CHECK NO.: 96-956
mNT 0 FIRE
0 FILE
0 PLAN REVIEWER
SET: I
PROJECT ADDRESS: 2906 Avenida Valera
PROJECT NAME: Shyu Residential Addition
0 The plans transmitted herewith have been corrected where necessary and substantially comply
with the jurisdiction’s *********** 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.
0 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.
0 The applicant’s copy of the check list is enclosed for the jurisdiction to forward to the applicant
contact person.
0 The applicant’s copy of the check list has been sent to:
Esgil Corporation staff did not advise the applicant that the plan check has been completed.
0 Esgil Corporation staff did advise the applicant that the plan check has been completed.
Person contacted:
Date contacted: (by: ) Telephone #:
REMARKS: 1. Note on the plans that all existing bed rms and corridors serving the bed rms will
be equipped with smoke detectors per UBC 310.9.1.2 2. Show on the plans that the relocated
8x5 window that is within 24’’ of the SGD must be tempered glass per the ‘94 UBC.
By: Chuck Mendenhall Enclosures:
Esgil Corporation
0 GA 0 CM 0 EJ 0 GP 0 PC 513 1 196 trnsrntl.dot
9320 Chesapeake Drive, Suite 208 4 San Diego, California 92123 4 (619) 560-1468 4 Fax (619) 560-1576
0
BUILDING PORTION
VALUATION AND PLAN CHECK FEE
JURISDICTION: Carlsbad PLAN CHECK NO.: 96-956
PREPARED BY: CM DATE: 6/6/96
BUILDING ADDRESS: 2906 Avenida Valera BUILDING OCCUPANCY: R3
TYPE OF CONSTRUCTION: VN
BUILDING AREA VALUATI 0 N VALUE
(sq- fit.) MU LTI PLI ER (8
Air Conditioning
Fire Sprinklers
TOTAL VALUE
1 addition I81 I94 I7614 I
7614
UBC Building Permit Fee:
UBC Plan Check Fee:
Comments:
$ 99.00
$ 64.35
Sheet I of 1
valuefee.dot
.
BUILDING PLANCHECK CHECKLIST
DATE: 6-/b 96
PROJECT DESCRIPTION: i# A3
~ECK NO. CB 7bd956
BUILDING ADDRESS: 90 h?u&&%&
ASSESSOR’S PARCEL NUMBER: J/h c & L c // EST. VALUE 7, &/4
ENGINEERING DEPARTMENT
APPROVAL
The item you have submitted for review has been
approved. The approval is based on plans, information
andlor 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 report can
result in suspension of permit to build.
A Right-of-way
construction of the following improvements:
permit is required prior to
DENIAL
Please see the attached report of deficiencies marked
with 0. 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: Date:
By: Date:
By: Date:
ATTACHMENTS ENGINEERING DEPT. CONTACT PERSON 0 Dedication Application
Dedication Checklist
Improvement Application
c] Improvement Checklist 0 Future Improvement Agreement 0 Grading Permit Application 0 Grading Submittal Checklist
Right of Way Permit Application 0 Right of Way Permit Submittal Checklist
0 Sewer Fee Information Sheet
and Information Sheet
A-4
City of Carlsbad
ADDRESS: 2075 Las Palmas Dr., Carlsbad, CA 92009
PHONE : (619) 438-1 161, Ext. 4-3 /5 m
P\DOCS\CHKCST\BP0001 .FRM REV 0-
2075 Las Palmas Dr. Carlsbad. CA 92009-1 576 - (61 9) 438-11 61 - FAX (61 9) 438-0894
BUILDING PLANCHECK CHECKLIST
SITE PLAN
PGdJ 3rdJ 1. Provide a fully dimensioned site plan drawn to scale. Show: mQp /a YOL ci-9o-a 3 North Arrow
Existing & Proposed Structures E. Easement-
@ Property Lines Easements
Existing Street Improvements @ Right-of-way Width & Adjacent Streets
0 2. Showonsite plan:
A. Drainage Patterns C. Existing Topography
B. Existing & Proposed Slopes
0 3. Include note: 'Surface water to be directed away from the building foundation at a 2%
gradient for no less than 5' or 2/3 the distance to the property line (whichever is less)."
[Per 1985 UBC 2907(d)5].
On graded sites, the top of any exterior foundation shall extend above the elevation
of the street gutter at point of discharge or the inlet of an approved drainage device
a minimum of 12 inches plus two percent' (per 1990 UBC 2907(d)5.).
4. Include on title sheet
A. Siteaddress
8. Assessor's Parcel Number
C. Legal Description
For commercial/industriaI buildings and tenant improvement projects, include: Total
building square footage with the square footage for each different use, existing sewer
permits showing square footage of different uses (manufacturing, warehouse, office,
etc.) previously approved.
EXISTING PERMiT NUMBER DESCRIPTION
Page 1 of 4
c
BUILDING PLANCHECK CHECKLIST
DISCRETIONARY APPROVAL COMPLIANCE ~std 2nd 3rd 0 [7 [7 5. Project does not comply with the following Engineering Conditions of approval for
Project No.
Conditions were complied with by: Date:
-
DEDICATION REQUIREMENTS
[7 0 6. Dedication for all street Rights-of-way adjacent to the building site and any storm
drain or utility easements on the building site is required for all new buildings and
for remodels with a value at or exceeding $ -pursuant to Code
Section 18.40.030.
Dedication required as follows:
Dedication required. Please have a registered Civil Engineer or Land Surveyor
prepare the appropriate legal description together with an 8-1 /2" x 1 1 plat map
and submit with a title report. All easement documents must be approved and
signed by owner(s) prior to issuance of Building Permit. Attached please find an
application form and submittal checklist for the dedication process. Provide the
completed application form and the requirements on the checklist at the time of
resubmittal.
Dedication completed by Date:
IMPROVEMENT REQUIREMENTS
0 0 0 7a. All needed public improvements upon and adjacent to the building site must be
constructed at time of building construction whenever the value of the construction
exceeds $ -pursuant to Code Section 18.40.040.
Public improvements required as follows:
- Please have a registered Civil Engineer prepare apprbpriate improvement plans and
submit them together with the requirements on the attached checklist for a
separate plancheck process through the Engineering Department. Improvement
plans must be approved, appropriate securities posted and fees paid prior to
issuance of permit.
Attached please find an application form and submittal checklist for the public
improvements requirements. Provide the completed application form and the
requirements on the checklist at the time of resubmittal.
Improvement Plans signed by: Date:
P\DOCS\CHKLST\BP0001 .FRM Page 2 of 4 REV 04/30/96
, * BUILDING PLANCHECK CHECKLIST
1stJ 2ndJ 3rdJ 0 0 0 7b. Construction of the public improvements may be deferred pursuant to code Section
18.40. Please submit a recent property title report or current grant deed on the
property and processing fee of $ so we may prepare the necessary Future Improvement Agreement. This agreement must be signed, notarized
and approved by the City prior to issuance of a Building Permit.
Future public improvements required as follows:
Improvement Plans signed by: Date:
notarized Agreement to the Engineering Department.
0 0 0 7c. Enclosed please find your Future Improvement Agreement. Please return signed and
Future Improvement Agreement completed by:
Date: da 0 7d. No Public Improvements required. SPECIAL NOTE: Damaged or defective
improvements found adiacent to buildina site must be repaired to the satisfaction of
the Citv Inspector prior to occuDancv.
GRADING PERMIT REQUIREMENTS
The conditions that invoke the need for a grading permit are found in Section 11 B6.030
of the Municipal Code.
c] 0 8a. Inadequate information available on Site Plan to make a determination on grading
requirements. Include accurate grading quantities (cut, fill import, export).
0 0 0 8b. 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 Gradina Permit must be issued and rouah aradina apDroval obtained prior
to issuance of a Buildina Permit.
Grading Inspector sign off by: Date: / df 0 8c. No Grading Permit required.
Page 3 of 4
BUILDING PLANCHECK CHECKLIST
\
2ndJ 3rdJ
9. 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. Types of work include, but are not limited
to: street improvements, trees, driveways, tieing into public storm drain, sewer and
water utilities.
Right-of-way permit required for
A separate Right-of-way permit issued by the Engineering Department is required for
the following:
&a 0 10. A SEWER PERMIT is required concurrent with the building permit issuance. The fee is noted in the fees section on the following page.
0 0 11. INDUSTRIAL WASTE PERMIT is required. Applicant must complete Industrial Waste Permit Application Form and submit for City approval prior to issuance of a Permit.
Industrial waste permit accepted by: Date:
Page 4 of 4
PLANNING DEPARTMENT
BUILDING PLAN CHECK REVIEW CHECKLIST
dn
di
da 0
Plan Check No. CB qh - QT6
APN: zi6 - q6 1 //
Address 2906 AVWlllP 1/ rtw
Planner Van Lvnch Phone (619) 438-1 161 ext. 4325
(Name)
Type of Project and Use:
Zone: &pY Facilities Management Zone: 6
CFD (iP CI e # (If property in, complete SPECIAL TAX CALCULATION
A 'bn t77a\/ -
WORKSHEET provided by Building Department)
Leaend & Item Complete 0 Item Incomplete - Needs your action
Environmental Review Required: YES NO TYPE
DATE OF COMPLETION:
Compliance with conditions of approval? If not, state conditions which require action.
Conditions of Approval
Discretionary Action Required: YES NO&' TYPE
APPROVAURESO. NO. DATE
PROJECT NO.
OTHER RELATED CASES:
Compliance with conditions or approval? If not, state conditions which require action.
Conditions of Approval
California Coastal Commission Permit Required: YES NO k
DATE OF APPROVAL:
San Diego Coast District, 3111 Camino Del Rio North, Suite 200, San Diego, CA 92108
Compliance with conditions of approval? If not, state conditions which require action.
Conditions of Approval
(61 9) 521 -8036
lnclusionary Housing Fee required: YES NO&
(Effective date of lnclusionary Housing Ordinance - May 21, 1993).
Site Plan:
1. Provide a fully dimensioned site plan drawn to scale. Show: North arrow, property
lines, easements, existing and proposed structures, streets, existing street
improvements, right-of-way width, dimensioned setbacks and existing topographical
lines.
2. Provide legal description of property, and assessor's parcel number.
Zoning:
1. Setbacks:
Shown 20'
Shown I-'pM
Shown
r Front: Required
Street Side: Required - Int. Side: R eq u i red ct
Rear: Required tor Shown ZSO'
-
2. Lot Coverage: Req ui red dq'a Shown Lag
3. Height: s?@v I Required ~~' Shown %!
4. Parking: Spaces Required 1 Shown 7
Guest Spaces Required Shown
Additional Comments
OK TO ISSUE AND ENTERED APPROVAL INTO COMPUTER DATE &/Jd
K:\ADMIN\COUNTER\PIANCK.FRM 1 -1 7-96
April 22,1996
Ming-o Shyu 2906 Avenida Valera Carlsbad. CA 92009
RE: Architectural Revlew Fieldstone Falrways
Homeowners Assoclation
IEW OF HO-ROV-T FORM
landscape
Architects
Per the request of the Board of Directors for Fieldstone Fairways Homeowner's Association we have reviewed the landscape submittal for your residence located at - 2906 Avenlda Valera in the Fairways Community and have the following comments;
As indicated by my previous review reports for the board, the CC&R's are not explicit in implementation of the landscape of individual lots and leaves the approval discretion to the Architectural Committee. As requested by the Architectural Committee, we have also agreed to review the plans. I am not approving the means nor methods of construction, the Installation and guarantee to the Homeowner and Homeowners Association. This is the sole responsibility of the landscape contractor. All existing walls and fences should be protected and not be filled against or altered in any way. All
existing drainage patterns should be maintained per the CC&R's. The CC&R's should take precedence In all situations.
SHYU Resldence The submittal included a landscape/hardscape plan for the front, back and side yards, as well s a remodeling plan, with details and specifications, for a room addition to the hous s Also, included in the submittal was an 8 1 /2" x 1 1 " sheet showing elevations of the landscape walls proposed for the front and back yards. There are some drain inlets shown on the plan. improvements for the front yard include a courtyard entry which contains walls (maximum height of 36") with pilasters, a wall fountain and tile inlay entry walk. Also, proposed for the front yard are walls and a walkway on the left side of the driveway (as viewed from the street) and planting areas which include Queen Palms as the only trees. Improvements for the back yard include a patio with tile inlay, a swim/spa, swim/spa equipment location, a room addition
shown as a "patio room', walls (maximum height of 48'1, raised planters, planting areas which show no trees and a satellite dish. Improvements to the left side yard include a service walkway, and a planting area which shows no trees. Improvements to the right side yard include a walkway and planting areas which show no trees. Althougn no? necessarily required, no irrigation plan, landscape construction details or landscape specifications were submitted as pad of the landscape submittal. Portions of the proposed materials of the hardscape and the landscape are in character of the Fairways project and I feel the submittal should be pudiulyAPPROVED with the
fok'owng cmdiNm:
1. me upplcunt has shown the proposed /oc&on of the scrte//e &h on the remodefing p/ot p/un, though no oiher informailon about the d13h wus submh'feo! The apphcunt $hui!.fsubm/;f in/o/mOtion about ihe suiel,e d/M us io diumeier of the d!h und overuk'/nsta//ed heighi for review and upprov.1 ?here b u noiuiion on the ReUsione fuii/wcrs Home0 wnen Associuiion Work Order ihui fhe 3aielIfe dhh was u/reudy hsiuled: The suienie dbh shul be udequuiei'y screened, wifh pluni muieriuL us io not be Wb/e from uny homeowner$ prope/fy or fiom any common urea The phi muferiu/ for screenhg shuk' be submifed for review and upprovdpdor io hsiuluiion. Jerry Leiher wlbe rewewing the sute/Me d2H for fnui upprovd
9885 Mesa Rim Road
Suite 101
San Diego
California 92 12 1
Phone: 6 19-452 5884
F~x: 619-452 5886
Page 2 The Fairways - SHYU Review of Home Improvement Report April 22,1996
2. The only p/cmts b'enfifibd on the phn are Queen Pal!, three total bcated in the fion f yard ihe applcan f &a17 not insfall any shrub or ground cover thaf I3 of an Invacjve wpe.
The swh/spa equipment sbaI7 be bcated per fhe CW of Cah"bad/Coun~ of Sun Diego Healfh Depadment requkemenfi. ihe applcant shall also vedw, through the Ciw of CarMad/Conw oi Sun Diego Healfh Depadmen f, saiew meawes requked fm a swh/$oa. For mample the applicant may be requi/ied to insfalla ~~c/~n~~~lafching~afe.
As menfimed above, allemng wa& and fences dould be protected and not be filed agahsf or a/tered ih any wa~ The faded p/anfers and the wall in the
back yard may create a condMm thaf w/;clfi//soi7 agaihsf an exkfihg ience. ihe uppicant shall ihsfall a secondary wall in both m&ed planters, wlh a mihimum gap of 6' between the secondary wall and the ex&fihg fence. The wal ih the
back yard may requke wals parallel to the exi3thg fence, again w#h a m/hihum gap oid'befween the wals and fie exMng ience.
No co/or or fin& &given for the propcwed wals ih the fiont yard Bofh the co/or
and finM texture shallmatch the house.
3.
4.
5.
6. The applcan t did a90 w some proposed drah Inlets however more may be necesary, for example behhd the wallh fie backyard in fie ra&edp/anters, and in the p/anters sbo wn in the dght side yard The exkfing drahage puffern
at the fime when overall gradihg was comp/efed by the Bu.7der & designed w#hout considerafion of proposed landscape hprovemenfs. FuIW, wak", mow sfn@, planter wa&, etc. wY entrap sudace wateL Allsun'oce wafer must have positive drahage away fiom the building and be co//ected in a
landsccrpe drainage sysfem. The ARC I3 not re$oomB/e fo/ Insfallation of proper draihage. ThI3 I3 the sole rewonsfBiP/ity of the owner and/or h& landscape Con~UCtOL
As Indicated above, the Installation Is the sole responsibility of the landscape contractor. The irrigation system should be designed with the ability to control different water zones (sun, shade, shrubs and lawn areas). The irrigation system should be reviewed routinely to avoid over spray. There should be a minimum slope/drainage of 2% away from the building and water should be collected in an atrium type catch basin in all shrub/ground cover areas. Planting areas shall be a minimum of 4" below the existing stucco screed on the building. All walks and walls that are adjacent to the existing building should have appropriate joint materials.
When you have met all the conditions listed above and completed all the approved improvements please fill-out the enclosed 'Notice of Completion ' form and mail to N.N. Jaeschke, in the enclosed envelope. You will be notified when a site visit to your home will be scheduled.
My recommended approval and the approval of the Board does not take precedence over the requirements and regulations of the City of Carlsbad. Please call with any questions or comments to the above-mentioned items.
Sincerely, .
Dolores Marquez, ASLA RIA 2453
cc: Janice Reeves c/o N.N. Jaeschke, Inc. 9610 Waples Street San Diego, CA 92 12 1-2992
WORKERS' COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain-a certificate of consent to self-insure for
the performance of the work for which this permit is issued.
- A. workers' compensation as provided by section 3700 of the Labor Code, for
I have and will maintain workers' compensation, as required by section 3700
B. of the Labor Code, for the performance of the work for which this permit is
issued. My workers' compensation insurance carrier and policy number are:
INSURANCE COMPANY POLICY NO. EXPIRATION DATE:
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS-FOR ONE HUNDRED
DOLLARS ($100) OR LESS)
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
C. workers compensation laws of California.
Signature
Warning: Failure to secure workers' Compensation coverage is unlawful, and shall be
subject an employer to criminal penalties and civil fines up to one hundred thousand
dollars ($1 OO,OOO), in addition to the cost of compensation, damages as provided for
in Section 3706 of the Labor Code, Interest and attorney's fees.
March 3, 1995
2075 Las Palmas Dr. - Carlsbad, CA 92009-1576 - (619) 438-1161 - FAX (619) 438-0894 @
I ' STATE C 0 M P E N SATlON INSURANCE
P.O. BOX 420807, SAN FRANCtSCO, CA 94142-0807
CARLSBAD, CA
I L
This is to certify that we have issued a valid Workers' Compensation insurance poticy in a form approved by the California
This policy is not subject to cancellation by the Fund except upon ten days' advance written notice to the employer.
We will also give you TEN 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
insurance Commissioner to the employer named below for the policy period indicated. c_
r
831 7
SAN DIEGO, CA 92119 NR I