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HomeMy WebLinkAbout355 Avenida CaballerosDate 07/06/2017 Submitted Owner CenterCourtHOA Contractor Western Pacific Roofing Architect Engineer Lot # Block # City Springs of Palm S rin s BUILDING PERMIT Building Address: 355 N Avenida Caballeros Unit 6-10 Case No. Permit Kim Floyd Technician Address Phone 75178 Gerald Ford Unit 1 B 760 202 9880 Palm Desert CA Address Phone 3462 La Campana Way 760-416-5877 Palm Springs CA Address Phone Address Phone Tract Parcel Number 508-540-021 Lot Size Zone Building Sq. Ft. Garage/Carport Use of building Permit Type condo Re -Roof Fire Sprinkler Units Valuation 31262.00 Occupancy Roofed Patio/Porch Permit Fees Paid 335.89 Lic. Number 235717 Remodeled Area Const. Type', Fixture Units Describe work in detail: Remove existing roof down to substrate & install Polyurethane foam roofing system, CRRC 0626-0010 SEPERATE PERMIT AND INSPECTION REQUIRED FOR REMOVAL AND REINSTALLATION OF MECHANICAL EQUIPMENT AND PHOTOVOLTAIC SYSTEMS. Special Conditions: Rooftop mechanical equipment must be on minimum six inch North building units 5-10 high sheet metal covered platforms or other approved support. Condensate lines must be in hard copper. Any hot tar roofing operation must comply with the California Fire Code and requires la permit from the Fire Department. DO NOT CONCEAL OR COVER ANY CONSTRUCTION UNTIL THE WORK IS INSPECTED IMPORTANT The issuance of this permit shall not be held to be an approval of the violation of any provisions of any city or county ordinance or state law. Inspections of work are subject to an approved set of plans being on the job. Changes to plans are not to be made without permission of the Building and Safety Divisions. The owner and/or contractor is responsible for establishing all property lines. All utilities must be underground. This permit will expire if work is not started in 180 days or if more than 180 days elapses between inspections. I certify that I am familiar with all requirements of the City of Palm Springs as they apply to this permit and understand that these requirements must be completed prior to final inspection and that no certification of occupancy will be issued until such time as these requirements are met. I certify that I have read this application and state that the information is true and correct. .G�WNEWONTRACTOR/AGENT '[ ATV This is a building permit when properly filled out, signed and validated, and is not transferable. ISSUED BY�I Finaled PERMITNUII 2017-2539 • INSPECTION INFORMATION No work shall be concealed without a signature by the inspector. The approved plans and this card must always be available to the inspector. Preserve this record. Every permit issued shall become invalid after 180 days unless a required inspection has been approved. Furthermore, permits expire when more than 180 days has elapsed from the date of the last approved inspection. CONSTRUCTION HOURS Weekdays 7am to 7pm Saturdays 8am to 5pm Sundays & Holidays Not Permitted J08 CARD Project address: 355 N Avenida Caballeros Unit Permit #: 2017-2539 Inspection hours 8AM'',- 4PM Monday - Thursday Inspection request line (760) 323-8243 Building Department (760) 323-8242 Building Department Fax (760) 322-8342 RE -ROOFS INSPECTIONS Clean, Patch, Flash: JOB NOTES: DO NOT ROOF UNTIL THE ABOVE IS SIGNED Roof Final: % 114 / W DEL. J4, SEPERATE PERMIT AND INSPECTION REQUIRED FOR REMOVAL AND REINSTALLATION OF MECHANICAL EQUIPMENT AND PHOTOVOLTAIC SYSTEMS. BUILDING PERMIT APPLICATION FOR BLOCK WALLS, POOLS, REROOFS,- & REP{PES DATE: Project 6*4�t- OA oR)4 UeVtu ,--"/c Owner's Name 9Z cog& A4 % 6oacaa5r fAffie Igh ne - 7 6Q - of 0,9 Owner's Address G Ex#W 6,Ao 0k7o; I A IN P Fs fwr, cg Canfractos Na mi t.J:s -re 2 . PIA �/ R ©oY.•s P%ene i 6 - .l b-108'>� contractor's Adchss. 3 q a 1114 cg P IVA tic-9 J �7 Eng*�geees Name. — - - hone # EtxMg re A0: s Lice . CQNTACT PERSON Address Phone Malls _ Height cfWa;ll Length of Wall Front Say Back . Re -roofs — S.P. cf Raof .5,500 Wt. of Material _ ES (iCEO) Deport / UL Listing _ Project Descripiicn lZ��oy£ �x�s<<NG SxsTfM /�aw� i Tofa! V`aiue of Wcr,, s Tli E SA f Uit FgT.44,-, "AM 4' ACQ/C/C GOA1i�L .ennG.n� S�ISJ^� 3SS niORrg AVj^Ita,+ C,494 tl-FRos G/z'RC-m* (0;�6-4d)U .=WliERE INDICATED BY A CHECK, SUgM 33-SETS (Minimum siie of pool plans lie X 1 M1rjiRium scale' 4 ❑ P,tot Plan with lot sgUarz footage. 0 PtanninglEng. Depa�tarter�t_ApprovaI. ❑ Structural Caleulat.-t , !€ . appircabla . Q Itaa€ or. -Truss 8nq., k apptiGab(e.: . 0 Plan far Pool with Wet Stamp fr©m Engineer. ❑ Wasfa; Drain & Vdht Isometric. ❑ Water flipirig. Isometric, dimensioned. .: i. ❑ Gas Piping lscsr efric., 666y.r BTU ratings. of each applianet- bin till bratitlies, disc nc e and placemi ' dM of longest ruh & total .BTU for Erffire system... SITE PLAN FOR POOLS MUST �E COMPLETE:_ MUST SHOW ENTIRE SITE, PROPERTY LINES, 8UtLDING. FOOTPRINT; [FORTH ARR6W, IL EGAL DESCRIPTION AND f'R4PER AD17RES3, 7 ♦Ot FPGM BOO u �0 PERMIT CENTER CITY OF PALM SPRINGS CASE#: TYPE: PR03ECT NAME APN1 ADDRESS 3.1372 MAA WESTERN PACIFIC ROOFING 1508-540-021 1355 AVENIDA CABALLEROS NORTH ZONING FEES ACCT #001-32212 ENVIRONMENTAL ASSESSMENT FEES - #001-32212 CHANGE OF ZONE APPLICATION 1$0.00 NEGATIVE DECLARATION PRE APP FEE 1$0.00 MITIGATED NEG DECLARATION CONDITIONAL USE PERMIT 1$0.00 CATEGORICAL EXEMPTION / NIR PLANNED DEVELOPMENT 1$0.00 DISTRICT APPLICATION FEE FINAL DEVELOPMENT PLAN FEE 1$0.00 VARIANCE APPLICATION FEE 1$0.00 INCLUDES SIGN VARIANCE TIME EXTENSION FEES 1$0.00 -- MISCELLANEOUS'/ LAND US 1$0.00 MISCELLANEOUS FZLZNG FEESACCT #001-34303 ARCHITECTURAL APPROVAL FEE 1$55.00 ADMINISTRATIVE MINOR 1$0.00 MODIFICATION FEES PLAN CHECKS PLANNING FEE 1$0.00 PLANNING CC AND R 1$0.00 MISCELLANEOUS /HSPB FEES 1$0.00 SUBDMSION FEES ACCT #001-32213 TENTATIVE MAPS FEES 1$0.00 FINAL MAPS FEES 1$0.00 LOT LINE AD3/CERT OF 1$0.00 COMPLIANCE FEE ENVIRONMENTAL ASSESSMENT FEE $0.00 MISCELLANEOUS FEE 1$0.00 MISCELLANEOUS FEES SIGN #001 - 32205 IN LIEU OF - #131-34359 R V - #001-32210 MISCELLANEOUS - #001-34106 0.00 MISCELLANOUS - #001-34308 SPECIAL EVENT - #001-34303 TOTAL FEES) $55.00 ce of an application or of a fee is not an entitlement or a permit to construct, change or alter any e property described in the application. ROM E RECEIVED BY DATE 7/6/2017 Customer ® Cashier ❑ Planning File ❑ Planning Copy 9270 otepzs,4, CITY OF PALM SPRIN Department of Planning ServicE 3200 E. Tahquitz Canyon Way, Palm Spri Tel: 760 323 8245 - Fax: 760 322 8360 FOR % (For Staff Use Onlyll I Planning Case Number:: Taken in by (Planner): / Date Submitted: CITY OF PALM SPRINGS, CALIFCRi ilA PLANNING DEPARTMENT CA 92262 STAFF APPROVAL --7 Staff Signature Date 6 Case # 0 With Conditions as follows: L-III or MINOR ARCHITECTURAL APPLICATION (MAA) TO THE APPLICANT: Please fill out the information requested below. Attach any signed authorization letters, drawings, color & material boards, photographs, cut sheets and/or any other materials necessary to describe the proposed project. E,19 Sr (31,.J G--' �,d1r'S / -1 PROJECT SITE INFORMAAT-ION.OVOQjY- 3LD6- t J)rr $ 10 Project Address: 3� J �� u� (f'9 (34 u 2o,5 APN: IS-OS'stio - 01; 1 (Number and Street name) (9-digit assessor parcel number ex: 000-000-oco) Project Name (example: Name of Condo Association or HOA): Zone: General Planji —00�zection/Township/Range:/4 / Lj Lot Area: )etailed Description of Project: Rim Ovi eAisri-'(G )eod ,,—& owl ;�0 �"H� Sv S1-,2,-r£ STjy c L pOG�/UQf ATJI14A11 �' ,4c12> 6 o0Y: i"!r-5 VSTEM Sq. Footage - Existing Bldgs Sq. Footage - Proposed New (if any): PROPERTY OWNER INFORMATION: Property Owner's Name: C �� R Cl1y 2 BOA- �r-oGa Co9Si £'NT fx 10Rt SCS Property Owner's Mailing Address: 7 �1 �2ALD fa/ll� t7f�, Syi,'£ % �j (Number and Street Name or pP.O. Box) L M �fsfar city, State Zip Property Owner's Phone:_') to 0 ✓ 4 0 -'? gg © Fax Property Owners Email: AUTHORIZED TO INITIATE THE WORK: Company Name:- WE .E%Zn> f1A GiA/G IQaOf,A:.;(r (Please print) I AM THE: OWNER - S AUTHORIZED AGENT (example CONTRACTOR ❑ LESSITE (TENANT) ❑ OTHER Agent's Name & Signature: Ad-1r,, ,f2 ��-- Agent's Mailing Address: 3y6 oZ L.,4 wA>/ Number and Street Name or P.O. Box) 0- city State Zip Agent's Phone: 7 60 Agent's Fax: 7 G 4 - 3oZ O cQ- Agent's Email: .��irH /��4,ti�t�2 WFST��L,�por"- CeA4 (Please continue to next page) 01/15/2015 02:56 7602027 GOLD COAST ENTERPPI PAGE 02/05 WESTERNPACUIC Roofing Corpetwdon Sandy Ivens Gold Coast Euterpxases 75178 Gerald Ford Dr. Suite IB Palm Desert, CA, 92211 Subject: Center Court ROA (Various unb) installation of a Pobmi retie Foam and Coating System, Dear Ms. Ivex►s: Thank you for the opportunity to submit a!-praposai for the re -roofing at the above referenced property. We are pleased to submit our PW I osd far the work as described below. The scope of work and associated costs axe as follovAM GENERA This proposal and contract is made between esteai pacific Roofing Corp. (Contractor) and the person (s) or en * named above (Owner). ess expressly stated to the coa�trary, the contractor sbali, be respoap1ble for performing the foils DESCREMON A. The general conditions of this standard 'an contract shall form a pant of these specifications with the same force and effort though repeated herein. B. The Couuwtor shall finish all labor, m&daI4 equipment, lasts, c0ntt2dWs licenses and insurance certifications to perform all operations required as specified. The contractor shall provide labor and material ous=umly included in work of the $ me naatum to give a quality, complete j ob. . C. if any unfibreseen or unexpected condi&W are cacountered duriaag the worlr and the conditions adversely affect the cost or progress of the work, the contractor will notify the ovaaaeir immediately, and the owner will negotiate a written ohange-order to resolve the unexpected condition be it for an incise or decrease #o the contract auaovnt 19 The Contractor shall occupy, use, and permit others to use the previisw only for the purpose of completing the work to be perforated pier this contract with the Miner. Contractor is to he ciVM all reasonable set-up and staging areas. Due to tbee limited access, some driveways :as may be blocked dmiag this coust=don process. 3462 La Campaua Way • Palm. Springs, CA.92262 • (760) 416-5877 • Fax (760) 320-8912 wwwwestpacroof.com - &mail: wprcps@,westpacroof.com 01 /,15/ 201 02: 56 7602027 GOLD COAST ENTERPPI PAGE 03/05 Center Court HOA January 122 2015 Page 2 E. Cottractor's scope of work shall not include the i6catifscation, detection, abste'mect, encapsEzMon or removal of asbestos or Similar hazardous substances incliding mold, .,ad, and bfesta on of mieds. If Contta= encountets any such products, matelals oz cond€tic. in the crr = of pezf=ing its work,, or if such hazardous material's are eacouutesed by any other fi=per&azing work at the jobsite send contractor dete mines that such mataials present a hazard to its employees, contraatar shall brave the right to discontinue its work and rcmave its employees from the jobsitc =tI1 such products or materials, and any bszards oo=ectcd therewith, we located and abated, encapsulated or r o3+ed, or it is dete==d tit no hazard exists ( as the case may requi-'e), and coEtrd= shWI receive an Utt0iOn of time to complete its work hereunder and =npensat on for delays encountered as a res* of such situation and correction- Due to the possiba IV of mold, •mildew and roden b b=g present before., dawg or after our work, CQntr GtOr'3 scope of work shall not imfude flte identification, detection or the removal of mold, mildew and rodents. owner agrees to hold Contractor ha mess, and shall. index =t Contractor hx=dess for any mold or rodent related ciaa m in the fxtum F. If a dispute shall arise between Contractor and Owner with respect to SAY matters or questions arising out of or xelaft to this contract or the breach thereof, such dispute shall be decided by arbitration administered by and in accordance with the Construction industry Arbitration Rules of the American Arbitration Association or through such arbitration procedt= as the patties may agree. This coat rae shall be specifically enforceable under the preva0mg arbitration law. 'The award rendered by the arbitrators shall be_£inal, and judgtnem map be entered upon it in any Court baying jurisdiction thereat G. Shculd suit be brought to enforce or interprct my.part of this Agreem ►t, the "prevailing park" sbaU. be entitled to rewver, as an element of costs of suit and not as datmages, Msonable attorneys' fees to be hied by the Court: The -pwvailing part'' shall be endued to recover its costs of suit; regardless of Wheffier such suit proceeds to final judgment. SU FA.CE PREPARATION A. Remove =Mng roof systetrz down to the substrate. B. Damaged sheathing wnl be replaced at a rate of $55.00 per sheet of portion thereof C. Prime roof deck with primer. APPLICATION OF POLYURETHANE FOAM AND COATWG A. Urethane bmIation shallbe spray -applied to a nomJvW thiclauess of 1.5" (plus or mains 1/2") Additional foam will be added to the low areas to belp maze ponding. Some ponding will remain. B. Coating shall be applied in a minimum of three separate coats. I. The base and kdermediate coats shall be applied at a rate of 125 gallons per 2. The top coat shall be applied at a rate of 1.50 gallons per 100 square feet, yielding a total system tlii"ess for &II coats of 30-32 TOTAL DRY MM& Top coat color to be quite. 3. Embed coramie granules h the wet top coat material at a rate of 50 pounds per 100 square feet. vursrM rACMC 2mfPe, CerpenN. a.ra• wrnrit 01/15/2015 02:56 7602027 Cexg Court HO;A, January 129 2015 Page 3 GOLD COAST ENTERPPID PAGE 04/ 05 4. Ali foam is to be coated. Coating shall extend ups and over all foamed vent pipes and termimied a wbimum of 2" above the foam, creaiimg A neat appearance, sel€trminating flashing CONTRACT A.MOUI Ts S11.4 .OQ (one Hundred Fourteen Thousand Eight Hundred Forty Dollars) North BuRdiar, $31 62.00 $6 Job 3y5cabn -i-ift MEAN" Fast Buie S26.12.00 P` Total[ $114,340 00 F%f-5—k Job* 1Li%MT,) NOTH #1: The RVAC waits mast be disconuectted and re -installed an taller .platforms with sheet meW covers. This work IS incladed in the contract amount. F.� MUSIONS: No items w1i be supplied nor work performed that is not speaficatly stated hereinn. pAYMENT TMIS., A Tea Percent (100/9) deposit upon approval of the Cont-Ut T wice- montbly payments vutij completion of contract. invoices to be paid wi& 10' days of receipL No retention to be held. Any =aaizQ.ug baiaucr due following completion to be paid within 15 days of receipt of the invoice. WAMIANTY A Ten (10) year labor and material warranty will be issued by Westem Pacific Roofing upon completion of the roof and final payment is received. Contractor's work wilt be wm7m ted by Contra. lu accordauce with its standard warranty, which is made..a part of thus proposal nd contract aud. incorporated by reference. A, copy of the Contractor's kaudard warranty is a wiled or, if not will. be fimaished upon request. Contractor SHALL NOT BE LIABLE F01k SPECZA .,, INCME J AL OR CONISEQUEN'TLAL DAMAGES. The acceptance of this proposal by the Customer signifies his agreement that thus warranty shall be and is the exclumve remedy against Contractor for all defects in workmasasbip furnished by Coutcaator. The Brice quoted has been stnrctared to reflect standards we assume are mutually desired: quality installadan, service reRahl ity and long -term performance. The price may be mbj ect to change 15 clays from. the date of this proposaL If you sre in accordance with the conditions herein, please execute the agreement below and 1d= bath copies to this olice. We will, in turn, sig a them and return we copy to you. Tbank you for In NOTICE TO OWNTt Contractors are required by law to be liccused and regulated by the Contractor's State License Board. Any quesfiiow concerning a contract may be referred to the Registrar, Conftwtoes State License Board, P.O. Box 2000, sr, rAj$26 or call 1-800-321-CSLB or www CSW.CAGOYfor more ` ,; � ry01 f 15/ 2015 02: 56 760202706 Center Court HOA ,Tanuaxp 12, 2015 Page 4 GOLD COAST ENTERPI& PACE 05/05 LAW,. REQUIRES knONE WHO CONTRACTS TO DO CONSTRtTCTION WORK TO BE LICENShD BY. THT ConjtA.CTORs STATB LICENSE BOARD IN THE LIC&NSE CATEGORY IN WHICH TEM CONTRACTOR IS GOANG TO BE WORIONG IF THE TOTAL PRICE OF THE JOB IS 9500 OR MORTs (INCLUDING LABOR AND MATERW4 ,,LICE1%iSz0 CONTRAMRS ARE REGULATED BY LAWS DES1IGNED TO PROTECT THE PCJr<TdC. IF YOU CONTRAcr wrM S0NM,0 vE WHO DOES NOT HAVE A LICXN, TILE CONTRACTORS STATE LICENSE BOARD MAY DR UNABLE TO ASSIST YOU WffH A C011iT'L.AINT. YOUR ONLY RIMY AGAINST AN UNUCINSW CONTRACTOR MAY BE IN CVM COURT, AND YOU MAY BE LLOLB FOR DAMAGES ARISING OUT OF ANY INJURIES TO THE CONTRACTOR OR TT15 OR HER PLOYBES. -YOU MAY CONTACT TEX CONTRACTORS STATE LICENSE BOARD TO FJND OUT 0 TUTS CONTRACTOR HAS A VALID LICENSE. TEM BOARD HA,S COMMETE nWORM TION ON TBE HISTORY OF LICENSED CONTRACTORS, INCLUDING .ANY POSSIBLE SUSF'MONS, REVOCATIONS, JUDGba= A" CITATIONS. THE BOARD HAS OFFICES THROUGHOUT CAIMORNIA. PLEASE CIIECK THE GOYERNbIENT PAGES OF THE WH1'I'E PAGER FOB TIM OFFICE NEAREST YOU OR CALL I-800-321-CSLB OR W-RE.CAB-C9.0Y FOR MORE, INFORMATION." ,A,LKN0Va=C,NjWT: Owner acknowledges that he/she has read and received a legible cow of this agreement ineiuding an terms and standard provisions before any work is performed and that he/she lies read and received a legible copy of every other document that owner has signed during this negodatioo. Vwe hereby acknowledge under the penalty of perjury that We amlare the legal owners and amlare asthortud to sign this contract as an agent of the legal owner. ACCEPTANCE: The above prices, specifications and conditions are satisfactory aced are hereby accepted. You are aatiiorized to do the Work as specified. Payment will be as outlined above. Yoa, the buyer may cancel this tr ssetion at anv time prior to midnight of the third business day 2fter the date of a& transacden. See the attached Notice of Cancellation for an explanation of this right: Owner has the right to require contractor to have a performance and payment bond at Owner's expense. CE SM COURT HOA Owner or Owner's Agent WESTERN PACIFIC RWFING, CORP. Contractors License # 235717 2&!2d-2 Ronald R. W"e i 1 I'll s- January 12, 2015 Date Hate WMW PA,CMC ROOW(G HAS nm RIGk'A'X' TO RESCIND TMS CONTRACT WTI YW FIFT.EISt DAYS OF ACWTANCL TE9SS AGREL)ENT IS NOT BiiY VG UNTIL ACCEPTED BY THE OFFICE M&NAMMM AT 3M2 LA CAWANA WAY. PALM SPRINGS, CA =62. NO CHANM OR A MMONS TO THIS AGX MMERNT SMLi, BE EFnCrtn UNTIL A.BAtLt1MM BY WkSTY;RIY FACMC MA,YAGII�r`l'.0 MAKAGERSACCEPT,AN D VMSTERN PACIFIC pa fls W. L.M9SlH OWNER 1 BUILDER DECLARATION I hereby of m under penaxy of perjury that lean exempt tircm the Comradurs UCOnie LAW for the foacwing reason (S�oe 70 31 A Misineaa and Profssxidnrsau a applrc Any or p rtr>u t ld a quiras�ermit to =%sbu Z attar. hWave, denchk or repair any Structure prier to its lsstrartm. rt►sa (Chapter 9 =ranan with Sec. 70G0 of OWis on 3 of ttto Business and Professions Codstatament that he or she is Inn3ed e) or that he or rsuant to me provisions he is exempt of tld Cantraaoes t basis Law ftr (C clog zrsmpt tharefrrm and the Esau ferdte ear ed ssamption. Any violation of Section 7031 A by arty acplicant far a permit subjects the SMIcant to a cMI penalty of not roars than Ave hundred dollars (32=I.) Please dwck one of the Following: , ❑ 1, as owner of the property, or my employees with wages as their solo oampensad=, will do the world, and the structure is not intended or grad for sale (Sea 704.4 of the Business and Prdfasslon Code: The Cantradcei Ltertse Law does not'appiy to an owner of property who builds or improves thereon, and who does strc,'t work himself or hers4lif or through his or her oven employees, provlded that such Impravernents era not intended or orllered for sale. If, however, lire building or lmprouenterlt is sold wittlin cne year of completion, the owner -builder will have the burden of proving that he or she did not build or imPrwe for the purpose of 3W*.) ❑ r,'as owner of The property,.am exdusively =ntracdng with ficansed, contractors to.ocnstruct the projed (Sec. 7044 of the Business and Prafesskns Code: The Contractor's W a•nso Law does not apply to an cWher of prtap0l;zwttd builds or improves thereon, acontracts nd who for such prged3 with a cantrador(s) tiicansed pursuant W the Ccnizac i Licarrse Low.) ❑ I am exarript raider Sac of the Business and Protes316ris Code for this Mason: 9. } ClvirnerSatura: Date:,,-' 'LICENSED CO TPL4CTORS DECLARA710H I hereby , under penty d perjury that I am ticansed under the provisions of Chapter 4 (=rattencng with Section 70II0) of Division 8 of the Business and Professions Code, and my loonse is i1 full lbroe and afoot The idling applies to a ors onty: I understand M Bmitatiens of Section 7t67 related to my abititj to tail` prime cwtracts or subconn= Involving spedaltry Wes. License Crass: o - state Lk. Na.: Clef Eus. Uc. No . o 0 41 �0 / Print Name on Lice ,lzl�S T"�R ti %�A C.-r r� � 24 4 Y r � �Flor�: ° 0e .11/a Adiamss: 3 yG _ L R CAM P4,Vg t v4 / P4 4 011 !-nary county or . which faRukrs the Iuwnca of a pemat as a tontdition precedent to the construction, aReration, imprt vertient, danotitim or tapaif of any txtft or structure sW require that Bath *V&:artt far the pemri sign a drbration under patali'j of perjury verifying worketrs';ccmpe �saiicn c.,+rerage or er�mptian ticrrt coverage as rsquirad by Sectiont982i of the Health and Safety Coda. (, tree i!RM under perratty cf perJury anti at the falwal"I deciamdons ' ❑ h HAVE M') WILL IVWN T Atli A CERTIFICATE TO SELF INSURE for wo*ees compensation as provided for by Sectian 3`r(h} of the Labor Cade, for the performance of the work for which this perink Is Issued. t _ e .. I HAVE MD WILL IdtAlNTAIN WORK>rRS GOMlPEhtSATiON lNSURWICE, as required by Section 3700 of the Labor Code, for the perforrnaka of the work for which this permit Is Issued. My workers' compensation Insurance tinnier and policy riurt=iber are: Carder. -u 0 L %0 AJ J Co n4 P1-Iti Policy No. 2 R L-JG / 9'Y Q 1200 r ❑ l CERTIFY'iitat in the performance of work for which this permit is issued, I SHALL NOT alp Loy ANY PEP,SCiPI, In any mamrter so as to become subject td the worker's compensation laws of California, and agree that if 1 'shodid become subject to the worker's compensation p vAslonsoof,Sedion 3700 of the Labor Code, I shall for with comply with'those provisions. Conhdtoro rAgents Signature: Date: % �' C9 V % lD