Loading...
12495 (SFD)P.O. BOX 1504 Building 54-°340 Carranza 78-105 CALLE ESTADO Address LA QUINTA, CALIFORNIA 92253 Owner TomaS Toles . maning Address City Zip Tel. Contractor Same City Zip I Tel. State Lic. I City & Classif. B 359948 Arch., Engr., Designer fit enell Address Tel. City (Zip (State Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. _SIGNATURE DATE OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason: (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 thathe 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 ($500). ❑'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, Buisness 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.) ❑ I, as owner of the property, am exclusively contracting with licensed contractors to con- struct 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 who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) O 1 am exempt under Sec. B. & P.C. for this reason -- ate_ _rOwner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) Policy NO. Company OiCopy is filed with the city. ❑ Certified copy is hereby furnished. ii CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) valuation 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 sutject to the Workers' Compensation Laws of California. Date Owner NOTICE TO APPLICANT: If, after making,this Certificate of Exemption you should become • subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. 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, Civil Code.) Lender's Name Lender's Address This is a building permit when properly filled out, signed and validated, and is subject to • expiration if work thereunder is suspended for 180 days. I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter the above-. mentioned property for inspection purposes. Signature of applicant Date Mailing Address City, State, Zip No. 12495 BUILDING: TYPE CONST. OCC: GRP._ A.P. Number 774-243-`025 Legal Description Lot 20 BlGck 288 Project Description QFC Sq. Ft. No. No. Dw. Size 2335 Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Permit does not include Mock walls or pool. Estimated Valuation $141,246.00 PERMIT Plan Chk. Dep. Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL REMAR re AMOUNT 14.12 1,267.19 1,28 .31 mt lot mercer ZONE- BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback'from Rear Prop. Line Side Street Setback from Center Line Side SetbackJQ m Property Line FINAL DATE rAV (NSP' EACTT O R // Issued by: .]IVU / UPe�mit n� r "U % lull Validated by: Validation: `�7 CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES UNDERGROUND `t IST FL. SQ. FT. ® $ UNITS 47 ROUGH PLUMB. YARD SPKLR SYSTEM 2ND FL. SQ. FT. @ STORAGE TANK FORMS MOBILEHOME SVC. BAR SINK POR. SQ. FT. ® DUCT WORK ROCK STORAGE GAR. SQ. FT. ® POWER OUTLET ROOF DRAINS METER LOOP DRAINAGE PIPING CAR P. I SQ. FT. ® RE] NF. STEEL WALL SQ. FT. ® DRINKING FOUNTAIN URINAL SQ. FT. ® WATER HEATER ESTIMATED CONSTRUCTION VALUATION $ FINAL INSP. WATER PIPING NOTE: Not to be used as property tax valuation FLOOR DRAIN MECHANICAL FEES FINAL INSP. tB-73-? WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER FINAL INSP2(� 1 GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED [� LAUNDRYTRAY AIR HANDLING UNIT CFM I KITCHEN SINK ABSORPTION SYSTEM B.T.U. TEMP USE PERMIT SVC WATER CLOSET' COMPRESSOR HP POLE, TEM/PERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SQ. FT. ® c BATH TUB SQ. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID @ 11/a c SEWAGE DISPOSAL SO.FT.GAR ® 3/ac HOUSE SEWER MESH GAS PIPING PERMIT FEE INSULATION/SOUND PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE PL.CK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE STRUCTURE / PLUMBING ELECTRICAL HEATING & AIR GOND. SOLAR SETBACK GROUND PLUMBING2_ UNDERGROUND A.C. UNIT COLL. AREA SLAB GRADE 47 ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK FORMS SEWER OR SEPTIC TANK ROUGH WIRING DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APP./EQUIP. RE] NF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM �p FINAL INSP. tB-73-? GRADING cu. yd. $ plus x$ =$ LUMBER GR. FRAMING G FINAL INSP2(� 1 ROOFING 3-31-d 0. Y L [� REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATION/SOUND FINISH NG FINAL INSPECTION/[ CERT. OCC. [v FENCE FINAL INSPECTOR'S SIGNATURES/INITIALS GARDEN WALL FINAL Building tJ_/_ Owner. Mailing Address . Cit _% Zip / Tel. Contractor Address Tel. State Lic. City & Classif. Lic. # Arch., Engr., Designer Address Tel. 4 4 " P.O. BOX 1'504 QUINOTA, CALIFORNIA 92253 11 City I Zip I State -�1 Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. SIGNATURE - '"`�` t` DATE OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason: (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 (5500). l: 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, Buisness 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 i of proving that he did not build or improve for the purpose of sale.) I 1 I, as owner of the property, am exclusively contracting with licensed contractors to con- struct the project. (Sec. 7044, Business and Professions Coder The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) I I I am exempt under Sec. B. & P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) Policy No. Company F1 Copy is filed with the city. ❑ Certified copy is hereby furnished. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) valuation or less.) I certify that in the performance of thg 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. Date Owner NOTICE TO APPLICANT: It, after making this Certificate of Exemption you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. 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, Civil Code.) Lender's Name Lender's Address This is a building permit when properly filled out, signed and validated, and is subject to expiration if work thereunder is suspended for 180 days. I certify that I have read thisapplicationand state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives -of this city to enter the above- mentioned property for inspection purposes. Signature of applicant Date Mailing Address City, State, Zip BUILDING DIVISION APPLICATION ONLY JILDING: TYPE CONST: .5� OCC. GRP. P. Number eqn ,gal Description VT O Project Description n 'N Sq. Ft. 33 No. No. Dw. Size Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ V41k W1, 2,6z fb4Z:2=Z ated Valuation PERMIT Plan Chk. Dep. Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL REMARKS �J1/Wbt, uI, 2A ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line Side Street Setback from Center Line Side Setback from Property Line FINAL DATE INSPOR Frn\ Issued by: tDAtA vermix_ Validated by: orT 1993 Validation: I �� CONSTRUCTION ESTIMATE GROUND PLUMBING NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. SO. FT. @ $ �1 n �2 �C/ _D UNITS BONDING HEATING (ROUGH) STORAGE TANK FORMS YARD SPKLR SYSTEM 2ND FL, SO. FT. @ DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) Q MOBILEHOME SVC. BAR SINK POR. S0. FT. Cw U TEMP. POLE GAR. SO. FT. @ �_ POWER OUTLET ROOF DRAINS FINAL INSP. BOND BEAM DRAINAGE PIPING CAR P. I SO. FT. 0 GRADING cu. yd. $ plus x$ =$ LUMBER OR. WALL SO. F7. @ FINAL INSP. FRAMING DRINKING FOUNTAIN SO. FT. @ ROOFING URINAL ESTIMATED CONSTRUCTION VALUATION $ REMARKS: WATER PIPING NOTE: Not to be used as property tax valuation -- FLOOR DRAIN MECHANICAL FEES WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LATHING LAUNDRY TRAY AIR HANDLING UNIT CFM KITCHEN SINK ABSORPTION SYSTEM. B.T.U. TEMP USE PERMIT SVC WATER CLOSET COMPRESSOR HP FINISH GRADING POLE, TEMIPERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. CERT. OCG. SO. FT. @ c BATH TUB FENCE FINAL SO. FT. @s c WATER HEATER MAX, HEATER OUTPUT, B.T.U. SO. FT. RESID @ 1'A c SEWAGE DISPOSAL SO.FT.GAR @ 3/ac HOUSE SEWER GAS PIPING PERMIT FEE PERMIT FEE n TOTAL FEES MICRO FEE MECH.FEE PL.CK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR SETBACK GROUND PLUMBING UNDERGROUND A.C. UNIT COLL. AREA SLAB GRADE ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK FORMS SEWER OR SEPTIC TANK ROUGH WIRING DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APPJEOUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM GRADING cu. yd. $ plus x$ =$ LUMBER OR. FINAL INSP. FRAMING FINAL INSP. ROOFING REMARKS: VENTILATION -- FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR ' GAR. FIREWALL LATHING MESH r INSULATIONISOUND FINISH GRADING FINAL INSPECTION CERT. OCG. FENCE FINAL INSPECTOR'S SIGNATURES/INITIALS GARDEN WALL FINAL DESERT SANDS UNIFIED SCHOOL DISTRICT 82-879 Highway 111 NOTICE: Indio, CA 92201 Document Cannot Be Duplicated 619-775-3500 Date 1/3/94 No. 112594 Type of Permit I La Quinta Permit # Log Owner Name Tom & Susan Toles No. 54340 Street Avenida Carranza city La Quinta Zip 92253 Study Area 111 APN # Tract # Lot # 0 Square Footage 12335 Type of Development Single Family Residence No. of units 0 Comments At the present time, the Desert Sands Unified School District does not collect fees on garages/ carports, covered patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes. It has been determined the above-named owner is exempt from paying school fees at this time due to the following reason: w This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of 1.65 x 2 335 or $ 3,852.75 have been paid to D.S.U.S.D. for the property listed above and that building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued. Fees Paid By Thomas Toles Name on the check By Dolores A. Ballesteros Superintendent Telephone Fee collected /exempted by Vickie J. Durrett Payment Received', S Signature -;;heck,*No: '0133 y Collector: Attach a copy of county or city plan check application form to district cop'v for all—vaive'rs. Embossed Original- Building Dept./ Applicant Copy - Applicant/Receipt Copy - Accounting `_ �� tom �' I t � �) - . � �t PS SRV FSP LOAF! DEPT ID : 619-325 3105 `� " ' JRN 07,' cj4: 1.0 04 N'6':'Ot 2 P : O2 COACHELLA VALLEY WATER DISTRICT;: A� 1� CASH RECEIPT DETAIL Received From: -iJ K. [/.., • i /o PM/ ► I .'� ��..�. Dafe'•!� Atltlree9;rJ �� �Q•iZ��`�'fji ih�%��-finIL tl_J ��l L�/ Account No. _>.6-.C.,la4.l LOL(6) _zyr,_y.�_ ' L Tract „.__ ��,�,_�?, ServIceAddreas 55.- V2, t" 1,C�'W6L-Z.4— G,A.Code f --- $d f- o" ❑ Backtiow(s) ❑ HouseLateral(s) C3 DetectorChook(s) ❑ Meter Surcharge _ enitatlon Capacity Charge , bi! SG _ 77 s;LS Q Temporary Construction Meter _ • Turn on Charge ❑ Uncollected Account - Name ❑ Inspection Fee • Tract - _ Fee- U Plan Check Fees Water / Sawer - Tract - n Bond Payment - A.D. -_Bond Aeamt. _ , ❑ Customer Deposit ❑ Other TOTAL Remarks: i ocoov to: Cash Water Service n t Check1�1 Money t-.:. Cashier_., Order CVWD-4 011AW CIO J W T L V J. ^� VOVI t\^ l V O� L-) TOLES 54340 Av. CARRANZA La QUINTA, CA. 2335 sq.ft. at 3 watts 7005va kitchen small appliance 3000va laundry 1500va ttl. 11505va 3000va at 100% 3OOOva 8505va at 35% 2977va ttl. net 5977va range 8000va cook -top 8000va dryer 5000va dishwasher 1200va pool equip. 2000va A.C. 1 5000va A.C. 2 3000va TOTAL 38177va 240v = 159 amps 200 amp service recommended ANDRE CARDINALLI CARDINALLI ELECTRIC CA. LIC. 471583 (619) 564-5098 City of La Quinta Building Department Re: Toles residence 54340 Avenida Carranza La Quinta All truses for the Toles residence at 54340 Avenida Carranza have been checked for all appropriate loads including extra loads for fireplace framing. If you have any questions please don't hesitate to call. sin erely w Mike Beck THE A.C. HOUSTON LUMBER Co. "Lumbermen Since 1884" 83-490 Indio Blvd./P.O. Box GG/Indio, California 922011(619) 347.3692 Installation Certificate: Residential CF -61 Use of this form to satisfy the requirements of the Administrative Code is optional, but the Information must be provided and posts f 54-340 Carranza 12495 Site Address Permit Number An installation cenilicate is required to be posted at the building site prior to the issuance of the occupancy permit. This form may be used to meet those requirements. All appliance categories istod below are the arcual equipment installed. Note that the efficiency and type of the appliance installed must be equivalent or better thanthe appliance specified on the Cortificate of Compliance (CF -IR). This certtticate (or its equrvalenf) shall be prepared and signed by the person(s) assuming overall responsibility for the appliance installation. I, the undersigned, verity that the equipment listed in the category above my signature is the actual equipment installed and that the equipmert.meets or exceeds the requirements of the Appliance Efficiency Standards. In addition, I have verified that the equipment is equivalent to or more efficient than the equipment specified on the Certificate of Compliance submitted to demonstrate compliance with the Energy Efficiency Standards for residential buildings. HVAC SYSTEMS Note: Hydronic boiler information is entered here. Other hydronic or combined hydronic equipment is listed under Water Heating Systems. Heating Equip. CEC Corlifiied Actual Distribution Duct or Heating Load Heating Type (furnace, Manuf. Make b Efficlency Typo and Piping Bofors Over- Equipment heat pump, etc.) Model Number (A UE, etc.) Location R -Value Sizing (Btuh) Capacity (Btuh CEC Certified Cooling Equip. Compressor Unit Actual Distribution Duct or Type (air cond., Manut. Make & Efficiency Type and Piping haat cum, etc.) Model Number . (SEER) Location R -Vacua The building design heat loss and design heat gain rate have been determined using a method specified in Section 150(h) of the Energy Efficiency Standards, and are two of the t reeria used for equipment sizing and selection. Signatim Date HVAC Subontratxor (Co. Mame) or General Contractor or Owner WATER HEATING SYSTEMS Energy' External Water Heating CEC Conifled Rated' Tank . Factor or Tank System Type Manut. Make 8 Input (kW Capactty Recovery Standby' Insulation (storage gas, etc.) Model Number or Btuh) Mallons) Efficiency Loss (%) R -Value 1. For small gas storage (rated inputs 75.000 Brj'hr), electric resistance and haat pump water heaters list Energy Factor. Far large gas storage water heaters (rated input 3.75.000 Stalhr). list Rated Input, Rctovery Efficiency and Standay Loss. For instantaneous gas water heaters. list Rated Input and Recovery Efficiency. For Instantaneous electric water heaters, list Rated Input. FAUCETS 3 SHOWER HEADS All faucets and showerhoads installed are listed in the Commission's Directory of Certified Faucets and Showerhoads, pursuant to Title 24, Part 6, Subchapter.2, Section 11 t. Signware Date Plumbing Subeontraeta (Co. Name) or General Contractor or Owner Revised January 1992 is to certify that we, in consideration of the total deposit premium and any mandatory surchar e of ��% — and the full premium to be adjusted later upon the total remuneration of employees during the policy period �to fT/_ `— , agree to issue 9 valid workers' compensation insurance policy in a form approved by theCaliforniaInsurance Commissioner to: THE EXECUTIVE OFFICE OF THE FUND RESERVES THE AUTHORITY TO GRANT INSURANCE COVERAGE AND THE RIGHT TO REJECT ANY AND ALL APPLICATIONS, BUT WHEN ACCEPTED, INSURANCE WILL.BE MADE EFFECTIVE AT 12:01 A.M. PACIFIC STANDARD TIME THE DAY FOLLOWING RECEIPT OF THE COMPLETED APPLICATION FOR CALIFORNIA WORKERS' COMPENSATION INSURANCE AND YOUR CHECK FOR THE DEPOSIT PREMIUM AND ANY MANDATORY SURCHARGE BY THE FUND UNLESS A LATER DATE IS REQUESTED BY YOU. STATE COMPENSATION IN S U R A N C E FUND NAMG es OF EMPLOYER CONTINUE IN SECTION 26 ►THE EXECUTIVE OFFICE OF STATE FUND RESERVES THE AUTHORITY TO GRANT INSURANCE COVERAGE AND THE RIGHT TO REJECT ANY AND ALL APPLICATIONS. BUT WHEN ACCEPTED. INSURANCE WILL BE AT 12A1 AM. PACIFIC STANDARD TIME THE DAY FOLLOWING RECEIPT OF THE COMPLETED APPLICATION FOR CALIFORNIA WORKERS COMPENSATION INSURANCE AND YOUR CHECK FOR THE DEPOSIT PREMIUM AND MANDATORY SURCHARGES BY STATE FUND UNLESS A LATER DATE IS REQUESTED BY YOU. g date R IS A FELONY FOR ANY PERSON TO WILLFULLY MISREPRESENT ANY FACT IN ORDER TO OBTAIN INSURANCE FROM STATE FUND AT LESS THAN THE PROPER RATES FOR SUCH INSURANCE, OR IN ORDER TO OBTAIN ANY PAYMENTS OUT OF STATE FUND. als 8 date 10 THE CONTENTS OF THE RISK EVALUATION QUESTIONNAIRE DATED _ I HAVE READ THE COMPLETED CONTENTS OF THIS APPLICATION AND ARE INCORPORATED BY REFERENCE INTO THIS APPLICATION. INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. SIGNATURE YE UT1N)T♦�D SIGNATURE GATE' BUSINESS PHONE HOYE PNONE I I I I IATEAJO3o/ff,� REVIEWED BY MINIMUM PREMIUM = $ _ DEPOSIT PREMIUM = $"— (NOT REFUNDABLE) 6 US RARR�ER INFORMATION NOTE 2920-C IER CODEMAM INTRODUCTORY PACKAGE SEM' POLICY DATES FROM TO a y OC — EVIOUS SCIF COVERAGE (POLICY NUMBER AND YEAR) ')// J 01- NOTE 2176 WCIRB NO. R NOTE 2940 SC1F PROSPECT NO. OPAYROLL REPORTING OR a. PAYROLL REPORTING FRE �E CY (A AYS COMPLETE THIS SECTION) p(� X 12 M 4 ❑ X 2 ❑ X 1 d. NOTE 2218 AUDIT AT OTHER N MAILING ADDRESS b. P/B CODE i C. POA FREQUENCY AND BILLING NOTES 2201 BILL div. # $ div. # $ BILLING div. # $ div. # $ FREQUENCY L �7 2202 BILL $ ❑ X 12 ❑ X 4 ❑ X 2 ® a P In CODE NO. sFxi LOC. itl RIPTION OF WORK BY FUNCTION OR DUTIES IEwL0EE5 I ESTIMATED PAYROLL 19 RATE I ^EsnYATEO PREM. G i I _ �— ! I I ! I I ! I CLASSIFI- CATIONS I i vIJM♦ ......�w.� I i DUTIES OF WORKING EXEC S/P S I I I EXECUTIVEPARTNER P/R I I I ' I \ 1 1 1 i SU&TOTAL PREMIU9 MODIFIM 2510 a P (CABLE EXPERIENCE MODIFICATION E"R I ^sol 2711 b CT10N X ! %I CATION ENDORSE- MENT 2710 c TOTAL POLICY MODIFICATION X I 2862 1 1 1 1 AX CODES 2500 THRU 3499 e OTHER SURCHARGE (IF ANY) X I TOTAL ESTIMATED PREMIUM $ Q — MANDATORY v�u� i'� = .�/0 0f UP as Wall. $ Z SURCHARGES ! MANDATORY SURCHARGES ARE DUE AT INCEPTION AND ADJUSTED AT FINAL BILL $ i I PAY THIS AMOUNT INCLUDES DEPOSIT PREMIUM AND MANDATORY SURCHARGES _ $1s�1 ►THE EXECUTIVE OFFICE OF STATE FUND RESERVES THE AUTHORITY TO GRANT INSURANCE COVERAGE AND THE RIGHT TO REJECT ANY AND ALL APPLICATIONS. BUT WHEN ACCEPTED. INSURANCE WILL BE AT 12A1 AM. PACIFIC STANDARD TIME THE DAY FOLLOWING RECEIPT OF THE COMPLETED APPLICATION FOR CALIFORNIA WORKERS COMPENSATION INSURANCE AND YOUR CHECK FOR THE DEPOSIT PREMIUM AND MANDATORY SURCHARGES BY STATE FUND UNLESS A LATER DATE IS REQUESTED BY YOU. g date R IS A FELONY FOR ANY PERSON TO WILLFULLY MISREPRESENT ANY FACT IN ORDER TO OBTAIN INSURANCE FROM STATE FUND AT LESS THAN THE PROPER RATES FOR SUCH INSURANCE, OR IN ORDER TO OBTAIN ANY PAYMENTS OUT OF STATE FUND. als 8 date 10 THE CONTENTS OF THE RISK EVALUATION QUESTIONNAIRE DATED _ I HAVE READ THE COMPLETED CONTENTS OF THIS APPLICATION AND ARE INCORPORATED BY REFERENCE INTO THIS APPLICATION. INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. SIGNATURE YE UT1N)T♦�D SIGNATURE GATE' BUSINESS PHONE HOYE PNONE I I I I IATEAJO3o/ff,� REVIEWED BY