Loading...
HomeMy WebLinkAbout021-320-024F hle. 't+a�y. ° "ter '4' o '" r .�• t. r RAY KROBER & LJA 1113 Dewsnu' AV Contr:Gree Va$ Works Yuba CytyPermit•-##42. 8 install.irri ation pump)SF 021-320-034 05-1976 WHELLER, ROBERT & MARIE" (� R 1161 ROWDY RD, GRIDLEY { I Cont: GALLAGHER'S HEATING ` HVAC (C/O) ; B07-2018 021-320-024 MISCELLANEOUS,- Electric Panel ELECTRICAL SERVICE CHANGE 1113 DEWSNUP AVE KROBER, RAYMOND : , • y <- . BUTTE COUNTY DEPARTMENT OF DEVELOPMENT SERVICES, BUILDING PERMIT 24 HOUR INSPECTION #:(530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO) OFFICE #:(530) 538-7541 FAX#: (530) 538-2140 WEBSITE: www.buttecounty.net\dds RICHALL ELECTRIC COMPANY RICHALL ELECTRIC COMPt Building Garage Remdl/Addn P.O.BOX 1847 P.O.BOX 1847 YUBA CITY, CA 95992 YUBA CITY, CA 95992 Other Porch/Patio Total (530) 673-4682 (530) 673-4682 -FEE INFORMATION.,r DBE Single Phase Service-Resid $58.00 . LICENSED CONTRACTOR'S DECLARATION Contractor (Name) State Contractors License No. / Class / Expires RICHALL ELECTRIC COMPANI 399919 / C10 / 02/28/2009 I HEREBY AFFIRM UNDER PENALTY OF PERJURY that I am licensed under provisions of Chapter (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Contractor's 09/25/2007 Date 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 WORKERS' COMPENSATION, as provided for by Section 3700 of the Labor Code, for the (performance of the work for which this permit is issued. HAVE AND WILL MAINTAIN WORKER'S COMPENSATION INSURANCE, as required by LLLIIILLIJJJ Section 3700 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; Carrier: ZENITH INSURANCEpolicy Number:C100C068620101 Exp. Date:10/01/2007 (This section need not be completed if the permit is or one hundre 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 Workers' Compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. X 09/25/2007 Signatl�re c ' Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR INSECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY, I HEREBY AFFIRM UNDER PENALTY OF PERJURY that there is a construction lending agency for the performance of the work for which this permit is issued. (3097 civ. code) Lender's Address City State Zip Total Charged: $58.00 Fees Paid: $58.00 Balance Due: $0.00 Receipt No: B4747 OWNER/ BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY 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 that 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 or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code] or that he or she 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]; Please check one of the following: ❑ 1, 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 the property, who builds or improves thereon, and who does the work himself or herself or through his or her 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 proof that he or she did not build or improve for the purpose of sale.). —]1. AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (Sec. 7044, Business and Provessions Code: The Contractor's License Law dows not apply to an owner of the property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractor's License Law.). ❑ 1 AM EXEMPT under Section B. & P.C. for this reason: Owner's Signature 09/25/2007 Date I hereby certify that I have read this application and stale that the above information is correct. I agree to comply with all City and County ordinances, rules, regulations, and State laws relating to building construction, and with any and all conditions of permit. I agree to defend, indemnify, and hold harmless Butte County, its officers, agents and employees from any and all claims and liability for personal injury, including death, and property damage caused by, arising out of, or in any way connected with the issuance of this permit. I hereby acknowledge that issuance of this permit does not authorize the use or occupancy of any sidewalk, street, or subsidewalk. I hereby authorize representatives of Butte County to enter the above mentioned property for inspection purposes. I hereby certify that I am the property owner or am authorized to act on the property owner's behalf. ,,,/_-_/1 / , ,. M_ ,. k< 09/25/2007 Owner Contractor OR. Agent for Owner ®Agent for Contractor a- FILE COPY PROJECT INFORMATION ' Site Address: 1113 DEWSNUP AVE Owner: Permit NO: $Q%-201$ APN:. 021-320-024 KROBER, RAYMOND Permit type: MISCELLANEOUS 1113 DEWSNUP AVE Issued Date: 09/25/2007 - By KCG Subtype: Electric Panel GRIDLEY, CA 95948 Expiration Date: 09/24/2008 Description: ELECTRICAL SERVICE CHANGE Occupancy: Zoning: A5 RICHALL ELECTRIC COMPANY RICHALL ELECTRIC COMPt Building Garage Remdl/Addn P.O.BOX 1847 P.O.BOX 1847 YUBA CITY, CA 95992 YUBA CITY, CA 95992 Other Porch/Patio Total (530) 673-4682 (530) 673-4682 -FEE INFORMATION.,r DBE Single Phase Service-Resid $58.00 . LICENSED CONTRACTOR'S DECLARATION Contractor (Name) State Contractors License No. / Class / Expires RICHALL ELECTRIC COMPANI 399919 / C10 / 02/28/2009 I HEREBY AFFIRM UNDER PENALTY OF PERJURY that I am licensed under provisions of Chapter (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Contractor's 09/25/2007 Date 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 WORKERS' COMPENSATION, as provided for by Section 3700 of the Labor Code, for the (performance of the work for which this permit is issued. HAVE AND WILL MAINTAIN WORKER'S COMPENSATION INSURANCE, as required by LLLIIILLIJJJ Section 3700 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; Carrier: ZENITH INSURANCEpolicy Number:C100C068620101 Exp. Date:10/01/2007 (This section need not be completed if the permit is or one hundre 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 Workers' Compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. X 09/25/2007 Signatl�re c ' Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR INSECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY, I HEREBY AFFIRM UNDER PENALTY OF PERJURY that there is a construction lending agency for the performance of the work for which this permit is issued. (3097 civ. code) Lender's Address City State Zip Total Charged: $58.00 Fees Paid: $58.00 Balance Due: $0.00 Receipt No: B4747 OWNER/ BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY 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 that 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 or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code] or that he or she 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]; Please check one of the following: ❑ 1, 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 the property, who builds or improves thereon, and who does the work himself or herself or through his or her 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 proof that he or she did not build or improve for the purpose of sale.). —]1. AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (Sec. 7044, Business and Provessions Code: The Contractor's License Law dows not apply to an owner of the property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractor's License Law.). ❑ 1 AM EXEMPT under Section B. & P.C. for this reason: Owner's Signature 09/25/2007 Date I hereby certify that I have read this application and stale that the above information is correct. I agree to comply with all City and County ordinances, rules, regulations, and State laws relating to building construction, and with any and all conditions of permit. I agree to defend, indemnify, and hold harmless Butte County, its officers, agents and employees from any and all claims and liability for personal injury, including death, and property damage caused by, arising out of, or in any way connected with the issuance of this permit. I hereby acknowledge that issuance of this permit does not authorize the use or occupancy of any sidewalk, street, or subsidewalk. I hereby authorize representatives of Butte County to enter the above mentioned property for inspection purposes. I hereby certify that I am the property owner or am authorized to act on the property owner's behalf. ,,,/_-_/1 / , ,. M_ ,. k< 09/25/2007 Owner Contractor OR. Agent for Owner ®Agent for Contractor a- FILE COPY w BUTTE COUNTY TTF0 DEPARTMENT OF DEVELOPMENT SERVICES 0 0 BUILDING PERMIT APPLICATION 0 o OFFICE #: (530) 538-7541 FAX #: (530) 538-214000 o =' "' o A FEE WILL BE REQUIRED AT TLYIE OFAPPLICA.TION Website: www.buttecounty.net/dds ���� **PLEASE PRINT CLEARLY** OWNER INFORMATION Last Name. � First �lar�e Mailing Address f s. /j ✓ e City C �� e Statp Zip P n1 7 Fax E-mail APPLICANT SIGNATURE X PROJECT LOCATION AP# 2_ Property Address L City , e PERMIT NO. BIN # WORKER'S COMPENSATION Policy Number L100 0 Carrier If hiring anyone other than license contractors, a certificate of worker's compensation must be shown at the time of permit issuance. LENDING AGENCY Name Address DESCRIPTION OR SCOPE OF WORK: r " Sq FT- Living Garage Open Cov ❑ Structure Built without Permits ❑ Proposed Change of Occupancy (Note previous use): , For office use only: CONTRACTOR Name C_/ c` l E Ie At ,, 0. Address Q t 7 CityLJ SN Zi4 �_ Ilq 2 w Zip . Fax E-mail Qriec Ulc� 73 Ll to State License Number Fa�) % 3'gto t S . E-mail Aa C Ala L d F_' cl 9 1 "Class C APPLICANT SIGNATURE X PROJECT LOCATION AP# 2_ Property Address L City , e PERMIT NO. BIN # WORKER'S COMPENSATION Policy Number L100 0 Carrier If hiring anyone other than license contractors, a certificate of worker's compensation must be shown at the time of permit issuance. LENDING AGENCY Name Address DESCRIPTION OR SCOPE OF WORK: r " Sq FT- Living Garage Open Cov ❑ Structure Built without Permits ❑ Proposed Change of Occupancy (Note previous use): , For office use only: ARCHITECT/ENGINEER Name ,c o, Address Address City Occ: State Zip Phone Zip . Fax E-mail Fax State License Number APPLICANT SIGNATURE X PROJECT LOCATION AP# 2_ Property Address L City , e PERMIT NO. BIN # WORKER'S COMPENSATION Policy Number L100 0 Carrier If hiring anyone other than license contractors, a certificate of worker's compensation must be shown at the time of permit issuance. LENDING AGENCY Name Address DESCRIPTION OR SCOPE OF WORK: r " Sq FT- Living Garage Open Cov ❑ Structure Built without Permits ❑ Proposed Change of Occupancy (Note previous use): , For office use only: APPLICANT INFORMATION Name ,c o, ) .� IPC T /' Co . Address No Occ: City State Zip . Phone Fax E-mail APPLICANT SIGNATURE X PROJECT LOCATION AP# 2_ Property Address L City , e PERMIT NO. BIN # WORKER'S COMPENSATION Policy Number L100 0 Carrier If hiring anyone other than license contractors, a certificate of worker's compensation must be shown at the time of permit issuance. LENDING AGENCY Name Address DESCRIPTION OR SCOPE OF WORK: r " Sq FT- Living Garage Open Cov ❑ Structure Built without Permits ❑ Proposed Change of Occupancy (Note previous use): , For office use only: Zoning Flood Zone SRA Yes No Occ: Type Const. Please sign and date where checked and send back to Butte County Bldg Department 7 County Center Drive Oroville, CA 95965 COUNTY OF BUTTS Attn: J.F. Glander DEPT. OF PUBLIC WORKS DEC 28 1981 AN M 71819000102111213141516 i I i I I i i I - i BUTTE COUNTY o ' DEPARTMENT OF DEVELOPMENT SERVICES. BUILDING PERMIT O 24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)E OFFIC#: (530) 538-7541 FAX#: (530)538-2140 - WEBSITE: www.buttecounty.netlidds PERMIT NO. BPO51976 UCENSEO CONYRACTORS DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter9•(commencing with Section 7000) of Division 3 of - Issued Date: -07/26/2005., APNO 02.1-320-034-000 - the Business and Professions Code, and my license is in full force and ' - effect. /' _/1% License Class t-O`uC� License Number ��?J3� Site Address: 1161 ROWDY RD GRI .. . Date: O.SContracto Map Index: " Descrlptlon: CHANGE'OLIT'HVAC`"" OWNE17431.1ILD DECLAMATION' "' " ' " I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5 Business and Professions Code: Any city or county which requires a Owner: WHEELER ROBERT SHERMAN & MARIE..:,..........,. permit to construct, alter, improve, demolish, or repair any structure, prior - THERESA to its issuance;.aleo requires the applicant for such permit to file a signed 'statement tha("he or she is licensed 'puftOant.to'tW provisions of P O' BOX 913.. the'C69tractor's State°License Law (Chapter 9 commencing with Section 7000) of Division 3,ofthe Business and Professions Code) or that he or. �i GRIDLEY, CA she+is exempt• therefrom'"and the basis for, the ;alleged exemption- Any . 9594.8. , ;;,? r ; �. •_ violation -of SeiUe 7031.5 by any applicant fora permit_subjects the.. y ✓ applicant.to `a ciyil',penalty of not more than five hundred dollars ($500).):: ❑ I, 'as,6wnerrofihe property, or my employees with wages as their sole compensation, will do the work, and the structure is not -_igtended or,offered for sale (Sec. 7Q44, Bustrtep.p9g J?rgfessjons. , . , ," _,. , , • ,.,. _ ,,.,,_ __-�_, , Code: The Contractors' State License Law does not apply to an .. .1.... Applicant: GALLAGHER'S HEATING &AIR owner;pf property who builds or improves thereon, and who does „ such jvork himself,or,herself.or,through.his orAer.own employees, provided that such improvements are not intended or, offered for E. HWY 99 sale:' It however, the' building or improvements are sold within one have LOS MOLINAS, CA year of completion, the owner -builder will the burden of 'proving that he or she did not build or improve for the purpose of 800-892-3556 sale.). 0-1, „as_owrler..of ,the ,property_ am -exclusively., contracting.. with. licensed contractors' to constfuct the project`(Sec. 7044, Business " -; and Professions- Code, The Contractorsr State License Law does -not apply loan owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed Contractor: GALLAGHER'S HEATING & AIR pursuant to the Contractors' StateLicenseLaw.). ❑ I am. Exempt under Article 3 of the Business and Professions Code' E. HWY 99 LOS MOLINAS, CA Date: " ' Y'" Owner: 800-892-3556 z,. "> ,. t;� W.ORKERS',CPMPENSATION `DECLARATION ,`- . rr. I hereby.aifirm,under penalty of perjury one of the following declarations:. License #: 777334 ❑ , I have and will maintain a certificate of consent to self -insure for workers' Wmpensation, .as provided for by Section 3700 of the babor. Code. , for the performance of the work for which this permit s Issued. •. _ ,�workers' I Architect:., .. _ - have and will maintain compensation insurance, as Engineer: g required by Section 3700 the Labor:Code, for the performance of the work for which this permit is.issued.. Myworkers'•compensation insurannce''•cca�arrier and policy number are: ' Carrier: Total Square Ft: 0 S. F. c��j5� — ap0� Policy >Y: r Valuation: $0.00 �„ ... , .... ,.- . •. ❑ I certify that in the performance of the work for which this permit is Census Code: issued:-) shall•not• emptoy any person in any manner so as to become subject"to the workers'. compensation laws of California. and .agree :that: if I should become 'subject to ,the workers' compensation provisions of Section 3700 of the Labor Code, I shall forth�witith comply with those provisions. Date: 77, APplicantx WARNING."" ailure to cure workers' compensation coverage is unlawful, -and shall subject an employer to criminal penalties and one hundred' :thousand' dollars' ($100,000), in 'addition to the cost of compensation,'damages as'provided for in Section 3706 of the Labor code, interestand attorney's fees.. —I , .. a .. ,. CONSTRUCTION LENDING AGENCY:.......... _.. This permit is hereby issued under the applicable provisions of the Butte Cnunty Code anrt/or I herebyaffirh that -there is'a construction lending agency for the of the work for which this is issued (Sec 3097 Civ.) Resolution do Mork indicated above for which fees have been paid. performance permit BY Date:// "� Name: PERMIT EXPIRES Address: Date O Thereby certifythat theyse of this facilityshalI comply with Sections 25505, 25533, and 25534 of the California Health and Safety Code, which regulate the storage, handling,and.use of hazardous materials.,, ❑ Notification' in accordance with'Section 19827.5 of California Health &� Safety Code is not applicable to the scheduled construction of this project. ❑ Attcheii are copies of the required E.P.A. notification forms. . . I hereby certify that,) have read this application, that the above information is correct, and that I am the owner or the duly authorized agent of the owner. 1 agree to comply with all county and state laws relating to building construction.,, l acknowledge itis unlawful to alter the substance of any official form r document of Butte County. I hereby ffrButttttee County to enter upon the above mentioned property for inspectio p o es. authorize representatives of _ �� L T �( G� LA—b 6--- ; Print Name" r 1 1 Signature Date: • ,•: * : �,.0 Owner O Contractor 1 ❑ Agent for Owner 0ent for Contractor BUTTE COUNTY DEPARTMENT OF DEVELOPMENT SERVICES BUILDING PERMIT APPLICATION AND SUBMITTAL REQUIREMENTS 24 HOUR INSPECTION#: OROVILLE: (530) 535-7636 • CHICO: (530) 891-2834 OFFICE #: (530) 538-7541 A FEE WILL BE REO UIRED AT TIME OF APPLICA TION Website: www.buttecounty.net/dds "'PLEASE PRINT CLEARLY" CONTRACTOR OWNER Last Name City s • Dil . ' Firs a Address ' ' �� a 9, _t C3� 7 Cityl. rid L4 on Zip Phone E-mail EFa CONTRACTOR ,,6 C Name G4 A l Address 3� City s • Dil . ' StateCn Zi S Phone ' `� ` I Fax `tr1 1 L611 L4 E-mail Lic. # -71, 3N I ft cs J APPLICANT NAME ARCHITECT/ENGINEER Name City Address Z' City v 1 Fax State Zip Phone Map Book Fax E-mail Planner State License Number APPLICANT NAME Nam C Address as City State Z' Phone (1 1 Fax Occ. E-mail APPLIqANT SIGNATURE For office use only: Zoning Property Addre i l d Flood Zone Cross Street SRA I Yes No Occ. Type Const. Subdivision Name Map Book Page 7t # Planner Date Approved: OVER FOR SUBMITTAL REQUIREMENTS K:\FORMS\BUILDING FORMS\BldgApplSubRgmts.doc PERMIT NO. BP BIN # LOCATION AP#�a I oZD d3 Property Addre i l d gyr lAf el— Cross Street WORKER'S COMPENSATION Policy Number 001 3 ac—f-D — Q-cO Carrier '-a+f -C-LA V1 d If hiring anyone other than license contractors, a certificate of worker's compensation must be shown at the time of permit issuance. LENDING AGENCY Name Address Description or Scope of Work: M D 1A -j- Sq. Footage ❑ Structure Built without Permits ❑ Proposed Change of Occupancy (Note previous use): EXPIRATION OF APPLICATION Applications for which a permit has not been issued will expire one year after the date of application. In order to renew action on an application after expiration, a new application, plans and fee will be required. REQUEST FOR REFUNDS Refunds can only be made upon written request by the person who paid the fee. The request must be made prior to the expiration of the permit and no construction work has been done. Filing fees, plan check fees for work plan checked and other department costs are not refundable. Received by: Amount: 155Bldg i�'/_ SRA Receipt #: Sheriff �i'3-,`? SMIP I I ther Date: r-1 Total I Page 1 of 2 REV 2-24-05 SUBMITTAL & PERMIT REQUIREMENTS The following drawings and specifications must be submitted to the Building Division in order to apply for a permit. INCOMPLETE SUBMITTALS WILL NOT BE ACCEPTED. ALL PLANS MUST BE LEGIBLE AND IN INK. ❑ 1. Site plans, 3 or 4 sets, signed by the preparer of the plans. No graph paper! ❑ 2. Complete plans, 3 or 4 sets, signed by the preparer of the plans (No graph paper!) OR Engineered plans, 3 or 4 sets, with wet signature on plans AND 2 sets of stamped and signed calculations. ❑ 3. Engineered truss details and layouts in duplicate (if required). No faxes! ❑ 4. Energy compliance design and supporting documentation in duplicate. ❑ 5. Statement of Intent for Non -heated and A/C for Non -Residential Buildings. ❑ 6. Manufactured homes: (A) installation inst, (B) Marriage line info, (C) Floor Plan, (D) Tie down or fnd plans, all in duplicate. ❑ 7. Metal bldgs: (A) Metal Bldg Plans, (B) Fnd plans and calcs in triplicate, (C) Elevations in triplicate. (D) Floor plans in triplicate. All of these must be stamped and wet -signed by the engineer. ❑ 8. Flood Elevation Certificate, wet -stamped and signed, in duplicate (if required). ❑ 9. Site plan and business license approval from the City of Biggs. ❑ 10. Letter of intent for non-residential buildings. ❑ 11. Detached Accessory Building Form filled out by the owner (if required). ❑ 12. Hazardous Material Form (for Commercial Buildings only). Remaining items needed to issue the permit. Additional items may be required after Plan Check and Planning review (May require additional plan review upon receipt of the following items.) ❑ 1. Agricultural Buffer clearance and site plan approval from the Ag Commissioner's office (if required). ❑ 2. Impact Fees. ❑ 3. California Department of Forestry plan approval (if required). ❑ 4. NPDES Form. ❑ 5. Encroachment Permit for driveway from the Public Works Dept. (construction approval prior to occupancy). ❑ 6. Contractor's license information. (Number, Name Style, Classification). ❑ 7. Worker's Compensation Carrier and Policy Number. ❑ 8. Owner -Builder Verification (if required). ❑ 9. Letter of Signature authorization (if required). ❑ 10. Recorded copy of Agricultural Acknowledgment Statement. ❑ 11. ❑ Grant Deed, ❑ M.H. Title/Statement of Facts. ❑ 12. Sanitation and site plan approval from the. Environmental Health Department. If you have questions or would like additional information regarding this process, please contact a Permit Assistant at (530)538-7541. EXPIRATION OF APPLICATION Applications for which a permit has not been issued will expire one year after date of application. In order to renew action on an application after expiration, a new application, plans and fees will be required. REQUEST FOR FEE REFUNDS Refunds can only be made upon written request by the person who paid the fee. The request must be made within two years from the date of fee payment on permits not issued, and two years from the date of permit issuance for permits issued; however, on issued permits refunds can only be made if no construction work has been done. Filing fees, plan check fees for work plan checked and other department costs are not refundable. OVER FOR BUILDING PERMIT APPLICATION KAFORMSWILDING F0RMS\B1dgApp1SubRgmts.doc Page 2 of 2 REV 2-24-05 Q� DuUz OROVILL.E- CALIFORNIA GENERAL CLAIM CLAIMANT: Green Valley Water Works .ADDRESS: 909-B N. Geo. Washington Blvd. CITY & STATE: Yuba City, CA 95991 IMPORTANT: December 22 1981 SEE INSTRUCTIONS DATE OF CLAIM: ON REVERSE SIDE SUBMIT CLAIM TO DEPARTMENT RECEIVING GOODS OR SERVICES. DATE DESCRIPTION OF CLAIM (DESCRIBE FULLY TO AVOID DELAY) i AMOUNT " 12/22/81. Contr, decided not to do work(Permit appin. IP4278-81E - Receipt.# " "..58356 & 58402 - AP..21-16-40--owners-.R. Krober & L. Adkins) Electrical permit "fee"paid--------------------- $47.50 Retain filtng tee------------------- Retain pre inspection fee----------- L1.50 MWUULLL . 50 Amount of refund due----------- $30.00 $3 00' TOTAL $30.00 I, the undersigned, declare under penalty of perjury that the services or articles claimed have be rf ed or e red, nd th t . � L/ claim is true and correct as stated. a:-r— �0 yy / � c XDated this ..........Grp..... ..... day ofr...`....... 19V�, 4t .......................... Calif. . . . ......... ...........:...... . ......... " Signature of _Claimant " •I, the undersigned, hereby certify that, to the best of my knowledge, the services or articles specified above hav bee performed or de- " ' livered and Wte is a Budget Appro iatio or Specificc Board Approval[] (Check one) for e s meDated thisday of v....... ... 19(1.1.. at ...... .Calif: ..... ...... .. ........ De artment Head or Authorized Depu Dept. Exp. Code Code PAYABLE FROM ....... ....................................................................... FUND . DO NOT WRITE BELOW THIS LINE - AUDITOR'S USE ONLY 'VENDOR CODE DEPT.. & SUB. PROD• SUB. OBJ. CLAIM N0: INVOICE N0. INVOICE DATE DISC. AMOUNT ENCUMB. SUB -DIST. y COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS PE_RMIT.NO. 7 County Center DrWe - Oroville, California 95965 - Telephone 916/534-4541 APPLICATION AND PERMIT ' ASSESSOR PARCEL NUMBER 0 _ 0443 _ a ZONING B DING PERMIT OWXR I� I, 5 A SAq( TELEPHONE SO. FT. OCC. BUILDING VALUATION OWNER'S MAILING ADDRESS-/ 3 s 14,6 ONTR AC TOR' NAME pL,�PI-19/ - (/� 7� Y O T R T O��t11,R//�///fS^�M_,�I Q �� /V• �jJjQs/7 !�� l•Ja4W (f7Vf, Fireplace CON,$ leON LENDER N NKNOWN Total Valuation $ Filing Fee g $ 10.00 LENDEFi•�AI LING ADDRESS ��//VV// Permit Fee $ ARd E OR ENGINEER Nf/�/��V/ LICENSE NO. Plan Checking Fee $ Penalty $ ARCHT OR ENGINEER'S MAILING ADDRESS NN Permit fee $ BUIL ING ADDRESS SQ�,y���gA111P�', Ay PLUMBING PERMIT Filing Fee 10.00 Each Trap 2.00 Repair drainage or vent piping 5.00 Water piping LOT NO. 14Q DIVISION NAME �/ 16PyI VI{.�+ C O"A PARCEL MAP 2� l'J Each qas water heater or vent 5.00 Gas piping system 1 - 5 outlets USE OF STRUCTURE SF)< Duplex❑ Mobilehome❑ Other SPECIFY Building sewer Lawn sprinkler system 5.00 TYPE OF WORK New ❑ Addition ❑ Remodel ❑ Uti lities Instal lation ❑ Other ❑ Describe work:66"rW&1C—_ 10�0*1,HO'o fl i� '� cQVV/J%? 7(', �A10-y%'��� Permit Fee $ Contractor ELECTRICAL PERMIT Filing Fee 10.00 Main service 100 AMP OR001 OR LESS5.00 O'FG� l� '/,v , n0� Main service EA. AD 100 AMP 2.50 'A 150 NEW CONST. DWELLING OCC UP:d) OR ADDNS. ACC, BLDGS. 20sgft CONTRACTORS LICENSE LAW I declare under penalty of perjury (check one): �( .4-ve- '�-'�I I am licensed under provisions of 840t. 9, Div. 3 of the Business and Professions ode a d m license 'fs in full rce aid effect. rA� y �� 6 �/ _ License No. S Classifidation ,T / , El 1, as the owner, or my employees with wages as their sole compen- sation, will do the work,,and the strup'ture isonot intended or offered for sale. (Sec. 7044)��`r'. z� �i� ❑ 1, as the owner, am excl ,!rely contracting wRh licensed contract- ors. (Sec. 7044) v'i F1 am exempt under Sec. -�, `�2+ Business ary&Professions Code for this reason " 17. -'� NEWCONSTPL-OUTLET 2,50 ea NON-RESID BRAN,H CIRC TS NEW CONST R. /POWER APPARATUS pit NON-RESID. SINGLE OUTLET CI,R. / 5o@2150 Ex. Occup OUTLETS OR FIXTURES 100 IXED APPLNS, OR Ex. OCCup.(OUTLETS (RESID.) EA. 2.00 Temporary service 10.00 s / 4&.90 ,SO Misc. Wiring 7.50 f (- %�s,�,� 10 3; Permit Fee $ 50 Contractor MECHANICAL PERMIT Filing Fee 10.00 WORKMEN'S COMPENSATION INSURANCE I declare under penalty of perjury (check one)? ❑ The permit is for $100.00 (valuation) or less. 1di I have placed on file with the County of Butte Building Department JPl a Certificate of Workmen's Compensation Insurance or a Certificate of Consent to Self -Insure. ❑ I shall not employ any person in any manner so as to become subject to the W. C. laws of California. Notice to Applicant: If after making this statement, should you become subject to the W. C. provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. Heating Cooling Hood 3.00 Ventilation permit Fee $ Contractor I certify that 1 have read this application and state that the above information is correct. I agree to comply to all County Ordinances and State Laws relating to building construction, and hereby authorize representatives of the Countyot Butte to enter u on the above-mentioned property for inspection purposes. I also agree save, indemnify an keep h less the County of Butte against all liabil' i dgmosts, nd ich may in any way accrue against a./ave, o equ ce o ing of this permz1f X Date �� Signature of Applicant — Owner ❑ Contractor JX Agent ❑ An OSHA permit is required for a cavations o7;,5'0" deep and emolition or construct- ion of structures over 33 stories in eight.ce Mobile Home Installation Fee $ TOTAL PERMIT FEE $ 47-6-0 oceuP, GROUP TYPE OF CONST. PARCEL PD ND ssuE This permit is hereby issued under sions of the Butte County Code and/or work indicated above for which DIRECTOR OF PUBLIC By PERMIT EXPIRES Date the applicable provi- resolutions to do fees have been paid. WORKS Date Receipt NO. 6-935611-7,50 J 40,, WHITE-D.P.W., YELLOW-ASSESSO , PINK-INSPE T R, GOLDENROD -Ell [CANT 0 PB 1T APPLICATION WORK SHEET Permit No. OWNER A. P. No. 2/-/(0- O Zoning U e Proposed Approved Not approved Permit fee based upon: '1. Complete contract price. 2. Partial contract price (explain). 3. DPW Valuation' (show): At time of permit application, the applicant was advised the following data or information must be submitted prior to permit processing and/or issuance: Date received 2. 3. �5. 6. 7. 11. 12. 13. 14. 15. RAI 18. All items have been submitted. -------------------------- Plot plans in duplicate/triplicate. --------------------- Complete plans in duplicate/triplicate. ----------------- Complete engineered plans and calcs. ------------------ Fees of of $ 0.o o -------------------- Letter of -signature authorization. ---------------------- Sanitationapproval. ------------------------------------ Planning approval for -- Workmen's Compensation Insurance Certificate. ----------- Contractors license information. ------------------------ Parcel declaration, recorded copy. ---------------------- Accessdeclaration. ------------------------------------- Aunt Minnie information. ----------- Deed of access, recorded copy. -------------------------- Deed of parcel creation, recorded copy. ,Parcel map, recording data. -- Pre -inspection request for• - - -- s ----------------- --------------- j ---- . Improvements - plans required & DPW approval. ---- ff- - Lh 12)a Bldg. Iyispiictor During plan checking process, the following data or information must be submitted rior to permit issuance: 1. Index permit for items above and in addition the fo owing: 2. Applicant advised by Telephone Mail Other 3. Plans checked by 4. Plans approved.by, Date Date When permit is issued, process as follows, 1. Mail to owner. 2. Mail to contractor. 3. Deliver with inspection. 4. Telephone and hold,, for pickup @ office. 5. Other Date //-/2-&/ Before permit issuance, all of the following items must be signed or marked NA: 1. Zoning use 2. Legal parcel 3. Envir.Health - Date Plans Sent _ A. Sanitation B. Restaurant C. Other 4. Public Works - Date Notice Sent 'A: Street Imp. B. Drainage C. Permits & Fees D. Other 5. Planning A. Use Permit B. Variance C.' Other 6. Other Agencies - Date Plans Sent A. Fire Dept. B. Other COUNTY OF BUTTE - DEPARTili�iEtVT 0 F 7 County Center Drive - Oroville, Caiifornia 95905 - 1., , PUBLIC WORKS PER%VT NO: Telephone 916/534-4541 APPLICATION AND PERMIT [_ASSESSOR PARC=L NUMBER ZONING tt Yti,FR TITELEPNON _. OWNER'SMAI! ING ADDRESS ry i! Glil/rf%r% flril �i't2i�it�—i` y 741' ,,CONTRA C TORj NAM= f T, t} FP!• NE CTOR'S M/A!1_1 G �%R E.55 r/191, i/:�';tP L fi✓s�fJ%� - — BUILMING PERMIT SO. FT. OCC. j \-SiBU!UDING VALUATION 1 _ " Fireplace �CCI',`RUC ON LENDER KNOWN - %y,1"� /// A 3 - J✓ - - LENOSR, ,+M.x;LtNG ADORC-,SS iJ- - at Tota! Valuation Filing Fee S 10.00 Permit Fee OR ENGINEER .-- /(/✓��_ LICENSE NO. Plan �,hPcking, t-ee `,Penalty . �"__-.� . ARC,h.I SC,T OR ENGINEER'S MAILING ADDRESS - ". aUILiti!NG ADORESS Glx^�Ii G Filing Fee .10.00 Each Trap �y 2:00 Repair drainage or vent piping 5:00 Water piping ,i LOT NO. SUBDIVISION NAME/� - - tai t PARCEc- ;eAa Each (las *water heater or vent 5.00 GaspiF i'^9y s stenl.l. - 5 outlets " - USEOF STRUCTURE8ui(ding S41 Duplex❑ Mobilehorte❑ Other } SPECT FY 5_ sewer Lawn sprinkler system. 5.00 TYPE OF'WOR'X -• Nevin Ad:;iticn❑ Remodel[] UtilitiesK Installation❑ Other❑.f Describe work: ` ` �f�!.% i 4 1G�c e'> L?ll >+ t91�10 D r �+fe�s-1`/D Dfw //V:5 Permit Fee Contractor_ � FilingFee ELECTI• it Z PERMIT n :.s- 10. 00 1 Main service 100 0 OR L t� 5.00 .100 AMP OR LESS .o ft .� V1� _ � �7 U _ 1,ee-Ltf' 0_,4/ / Main service EA. ADD'L. 100 AMP J) 2.50 �i'75.i t NEW CONST. DWELLING OCCUP. ni OR ADONS. ( ACC. SLOGS. j 24 sq it _ . . CONTRACTORS:LICENSE LAW ! declare under pena!ty'of perjury (check one):,, y ! am license under provisions of Ghapt.9, Div. 3 of the Business. I and PrOfessipris ode a d my license-rs In full force and effect.. License No. 3` �� `� Cl Seel fl C2llQfl ^� + Eli, as- the .owner, or my employees with Naees as their sole compen- sation, will do the workarid the structure is not intended or offered fcr sale. (Sec. 7044) " •- ,. ❑ I, as the owner, am ey:clusiyeiy contracting ivlth 1'icensed eQntr ct- i ors. (Sec. 7044) :- 9 am exempt under Sec. Business and Professions Code for.this reason w " NEY/ CONS?FL NULTLOUTLE NDN-RES{D. BR API C. CIRCUITS 2.50 e2 NEW CONST *7. (/POWER AP PARATIIS e NON-P.ESID.. SINGLE OUTLET CIR. 50 L' EX. Occup�OUT LETS OR FIXTURES SALCeI FIXED APPLNS. OR EX_ Occup.( MESIDJ EA.) Z.O� 'E Temporary service 10.00 .. s Misc. Wiring 7.50 �1) Sf7 fP . ' �.+`y` Permit Fee Contractor MECHANICAL IPERAIII3' Filing Fee 10.00 WORKMEN'S COMPENSATION INSURANCE I declare under penalty of perjury (check one): = ❑ The permit is for 5100.00 (valuation) or less. I have placed on fiie with the County of Butte Building Department a Certificate of Workmen's Compensation Insurance or a Certificate of Consent to Self -insure. ❑ I shall. not employ any person in any manner so as to become subject to the W. C. laws of California. Notice to Applicant: If after making this statement, should you become subject to the W. C. provisions of the Labor Code, you must forthwith comply with such 070v si0rs 0r this permit shall be deemed revoked. Heating Cooling Hood 3.00 Ventilation permit Fee S Contractor 1 certify that I have read this application and state that the above Information I is correct. I agree to comply to all County Ordinances and State Laws relating to building construction, and hereby authorize representatives of the County of Butte to enter upon the above-mentioned property for inspection purposes. ! also agree tysave, indemnify and keep h Tess the County of Butte against . ail iiabil ! iudgm Ftosts, nd ich may in any way accrue rmit. I againstelunty ods>au ce o Ing of this p7/X, �� IjThis y�t. - Signature of Applicant —' Owner ❑ Contractor ( I Agent ❑ / A.:; OSHA permit is required far a cevctions oY r 5'0" deep and , emolition or construct- ;or, of sttuctures over 3 stoias in eight. ---- Mobile home fnstallatiori Fee 5 ZA TOTAL PERMIT FEE $ 47 • occu R. GROUP TYPE of CONST. PARCEL vQ NO IZSCE [ 1.P permit is hereby issued under the applicable provi-Date sions f the Butte Count Code and/or resolutions to do o y work indicated above for which fees have been aid. �. DIRECTOR OF PUH,f-IC WORKS lB�y pC p C Date T�RT�f9 G��frl �.) Date ! Receipt No. �✓o 1'7,Lt PINK-IYSPErrT OR. COLONR0- PLI CANT' wj11T=-O.P-'N.. YELLOW-ASSESSO.y, _ 7 0 Iq7� ` P FT,URAiVCE COMPANY } E NORTH AMERICA milift - II STANDARD WORKMEN'S COMPENSATION I AND EMPLOYERS' LIABILITY POLICY DECLARATIONS Item 1. 1 GREEN VALLEY WATER WORKS t INC. AND ( PAGE 1 LAST PAGE) . Nameof HAL LEDBETTERy INDIVIDUALLY . Insured 909 B NORTH GEORGE WASHINGTON BLVD, -CA. POLICY NUMBER YUBA CITY9-CA. 959.91 ?�C C1 71 36 99 g Address . L Ell - nd - ividual ❑ Partnership poration Locations - All usual workplaces of the insured at or from which operations covered b®hisrPolicy are conducted are located at the abov address unless otherwise stated herein: STATE OF CALIFORNIA , Item 2. Policy Period: From 11-05-81 to 11-05-82 12:01 A.M., standard time at the ad- dress of the insured as stated hereir Item„3. Coverage A of, this policy applies to the workmen's compensation law and any occupational disease law of each of the following states CALIFORNIA Item a. classification of Operations Entries in this item, except as specifically provided elsewhere in this policy, do not modify any of the other provisions of this policy. SALESMEN, COLLECTORSORMESSENGERS-- OUTSIDE CLERICAL "OFFICE EMPLOYEES --N..0,.00'_ ELECTRICAL MACHINERY. :OR AUXILIARY A.PPARATUS=INSTALLATION OR R,EPAiR— INCLUDING INCIDENTAL MIRING PLUMBING--N.O.C.—=SHOP AND OUTSIDE—=GAS, ST€AMv HOT WATER OR OTHER PIPE FITTINGS INSTALLATION, --INCLUDING HORSE CONNEC— TIONS INSTALLATION ESTIMATED STANDARD POLICY PREMIUM ESTIMATED STANDARD•DEPOSIT PREMIUM! Minimum Pre'rni f Indicated herein, interim adjust- ments of premium shall be made: A Semi-AnnuallyElQuarterly Vumbers of endorsements forming a part of this policy on its effective date: Premium Basis Code Estimated Total No. JAnnual Remunerat -8742 IF•ANV 8810 180000* r: : �J:.. Rates Per $ 700 of Estimated Remuneration Annual Premiumi .75 0. .42. 76. 3724 I 10000. I 6.99 5183 .I 10000. I 5.37 699, I I 1537. 1312. 787. Total Estimated Annual Premium $ 1312 (.LAST PAGEV. ❑ Monthly Deposit Premium $ 787 LC169 LC1535 LC815• em . IM of Liability for Coverage B— Employers' Liability: $ 1009 000, subject to all the terms of this policy having reference thereto Interstate Identification Number: Employer's S to I entification N . ® New; ❑ Renewal; ❑Rewrite. of; • . Countersigned By VXW) �2” .c -j FN SYM PREVIOUS POLICY NO. ( thorized Agent) AGENT: NORTH VALLEY INSURANCE ASOC. SERVICE OFFICE pSAC6dA�lENTO _ 01293 �� b �aTtC 4 WCu.�.A.. 7 9� 0,ZL�i�+nt { C -q-,Z a d q{� 1#i3sd'if'�+Mr,.. ts:y�.flbc•r •:� _ .tfi?s 4�__i �.._ Y_ttf1N]'Jeidb3-� ��i .3c..«y����frrki K�'3�_ ! 1� t s ( INSURANCE COMPANY OF NORTH AMERICA, PHILADELPHIA, PENNSYLVANIA GREEN VALI EY .WATlER WORKS, INC. HAL LEDBETTER, INDIVIDUALLY 909 B NORTH GEORGE WASHINGTON YUBA CITY* CA. 95991 T.*1 e :l9 am ANftu'.f s x r , (A stock insurance company, herein called the company) Agrees with the insured, named in the declarations made a part hereof, in consideration of the payment of the premium and in reliance upon the statements in the declarations and subject to the limits of liability, exclusions, conditions and other terms of this policy: INSURING AGREEMENTS I. Coverage A—Workmen's Compensation To pay promptly when due all compensation and other benefits required of the insured by the workmen's compensation law. Coverage B—Employers' Liability To pay on behalf of the insured all sums which the insured shall become legally obligated to pay as damages because of bodily injury by accident or disease, including death at any time resulting therefrom, (a) sustained in the United States of America, its territories or possessions, or Canada by any employee of the insured arising out of and in the course of his employment by the insured either in operations in a state designated in Item 3 of the declarations or in operations necessary or incidental thereto, or (b) sustained while temporarily outside .the United States of America, its ter- ritories or possessions, or Canada by any employee of the insured who is a citizen or resident of the United States or Canada arising out of and in the course of his employment by the insured in connection with operations in a state designated in Item 3 of the declarations; but this insurance does not apply to any suit brought in or any judgment rendered by any court outside the United States of America, its territories or possessions, or Canada or to an action on such judgment wherever brought. II. Defense, Settlement, Supplementary Payments As respects the insurance afforded by the other terms of this policy the company shall: (a) defend any proceeding against the insured seeking such benefits and any suit against the insured alleging such injury and seeking damages on account thereof, even if such proceeding or suit is groundless, false or fraudulent; but the company may make such investigation, negotiation and settlement of any claim or suit as it deems expedient; (b) pay all premiums on bonds to release attachments for an amount not in excess of the applicable limit of liability of this policy, all premiums on appeal bonds required in any such defended proceeding or suit, but without any obligation to apply for or furnish any such bonds; (c) pay all expenses incurred by the company, all costs taxed against the insured in any such proceeding or suit and all interest accruing after entry of judgment until the company has paid or tendered or deposited in court such part of such judgment as does not exceed the limit of the company's liability thereon; (d) reimburse the insured for all reasonable expenses, other than loss of earnings, incurred at the company's request. The amounts incurred under this insuring agreement, except settlements of claims and suits, are payable by the company in addition to the amounts payable under coverage A or the applicable limit of liability under coverage B. III. Definitions (a) Workmen's Compensation Law The unqualified term "workmen's compensation law" means the workmen's compensation law and any occupational disease law of a state designated in Item 3 of the declarations, but does not include those provisions of any such law which provide non -occupational disability benefits. (b) State The word "state" means any State or Territory of the United States of America and the District of Columbia. (c) Bodily Injury by Accident; Bodily Injury by Disease The contraction of disease is not an accident within the meaning of the word "accident" in the term "bodily injury by accident" and only such disease as results directly from a bodily injury by accident is included within the term "bodily injury by accident." The'term "bodily injury by disease" inciudes only such disease as is not included w thin the term "bodily 'injury by accident." (d) Assault and Battery Under coverage B, assault and battery shall be deemed an accident unless committed by or at the direction of the insured. IV. Application of Policy This policy applies only to injury (1) by accident occurring during the policy period, or (2) by disease caused or aggravated by exposure of which the last day of the last exposure, in the employment of the insured, to conditions causing the disease occurs during the policy period. EXCLUSIONS This policy does not apply: (a) under coverages A and B to operations conducted at or from any workplace not described in Item 1 or 4 of the declarations if the insured has, under the workmen's compensation law, other insurance for such operations or is a qualified self -insurer therefor; (b) under coverages A and B unless required by law or described in the decla- rations, to domestic employment or to farm or agricultural employment; (c) under coverage B, to liability assumed by the insured under any contract or agreement, but, this exclusion does not apply to a warranty that work per- formed by or on behalf of the insured will be done in a workmanlike manner; (d) under coverage B, (1) to punitive or exemplary damages on account of bodily injury to or death of any employee employed in violation of law, or (2) with respect to any employee employed in violation of law with the knowletge or acquiescence of the insured or any executive officer thereof; (e) under coverage B, to bodily injury by disease unless prior to thirty-six months after the end of the policy period written claim is made or suit is brought against the insured for damages because of such injury or death resulting therefrom; (f) under coverage B, to any obligation for which the insured or any carrier as his insurer may be held liable under the workmen's compensation or occupational disease law of a state designated in Item 3 of the declarations, any other workmen's compensation or occupational disease law, any unemployment com- pensation or disability benefits law, or under any similar law. 91rcF} x41 3� rY3�h 4,r ' :CONDITIONS CONTINUED As between the employee and'the company; notice or knowledge of the injury on the part of'the insured shall be notice or knowledge, as the case may be, on the part of the company; the jurisdiction of the insured, for the purposes of the workmen's compensation law, shall be jurisdiction of the company and the company shall in all things be bound by and subject to the findings, judgments, awards, decrees, orders or decisions rendered against the insured in the form and manner provided. by such law and within the terms, limitations and pro- visions of this policy not inconsistent with such law. All of the provisions of the workmen's compensation law shall be and remain a part of this policy as fully and completely as if written herein, so far as they apply to compensation and other benefits provided by this policy and to special taxes, payments into security or other special funds, and assessments required of or levied against compensation :insurance carriers under such law. The insured shall reimburse thq company for any payments required of the company under the workmen's :ebmpensation law, in excess of the benefits regularly provided by such law, solely because of injury to (a) any employee by reason of the serious and wilful misconduct of the insured, or (b) any employee employed by the insured in violation of law with the knowledge or acquiescence of the insured or any executive officer thereof. Nothing herein shall relieve the insured of the obligations imposed upon the insured by the other terms of this policy. 9. Limits of Liability—Coverage B The words "damages because of bodily injury by accident or disease, including death at any time resulting therefrom," in coverage B include damages for care and loss of services and damages for which the insured is liable by reason of suits or claims brought against the insured by others to recover the damages obtained from such others because of such bodily injury sustained by employees of the insured arising out of and in the course of their employment. The limit of liability stated in the declarations -for coverage B is the total limit of the company's liability for all damages because of bodily injury by accident, includ- ing death at any time resulting therefrom, sustained by one or more employees '.in any one accident. The limit of liability stated in the declarations for coverage 'Bis the total limit of the company's liability for all damages because of bodily injury by disease, including death at any time resulting therefrom, sustained by one or:more employees of the insured in operations in any one state desig- nated in Item 3 of the declarations or in operations necessary or incidental thereto. The inclusion herein of more than one insured shall not operate to increase the limits of the company's liability. 10. Action Against Company—Coverage B No action shall lie against the company unless, as a condition precedent thereto, the insured shall have fully complied with all the terms of this policy, nor until the amount of the insured's obligation to pay shall have been finally determined either by judgment against the insured after actual trial or by written agree- ment of the insured, the claimant and the company. Any person or organization or the legal representative thereof who has secured such judgment or written agreement shall thereafter be entitled to recover under this policy to the extent of the insurance afforded by this policy. Nothing contained in this policy shall give any person or organization any right to join the company as a co-defendant in any action against the insured to determine the insured's liability. Bankruptcy or insolvency of the insured or of the insured's estate shall not relieve the company of any of its obligations under coverage B. 11. Otherinsurance If the insured has other insurance against a loss covered by this policy, the company shall not be liable to the insured hereunder for a greater proportion of such loss than the amount which would have been payable under this policy, had no such other insurance existed, bears to the sum of said amount and the amounts which would -have been payable under each other policy applicable to such loss, had each such policy been the only policy so applicable. 12. Subrogation In the event of any payment under this policy, the company shall be subrogated to all rights of recovery therefor of the insured and any person entitled to the benefits of this policy against any person or organization, and the insured shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights. The insured shall do nothing after loss to prejudice such rights. 13. Changes Notice to any agent or knowledge possessed by. any agent or by ,any, other person shall not effect a waiver or a change in any part of this policy of estop the company from asserting any right under the terms of.this policy; nor shall the terms of this policy be waived or changed, except by endorsement issued to form a part of this policy. 14. Assignment Assignment of interest under this policy shall not bind the company until its consent is endorsed hereon. If, however, during the policy period the insured shall die, and written notice is,given to the company within thirty days.after the date of such death, this policy shall cover the insured's legal representative as insured; provided that notice of cancelation addressed to the insured named in the declarations and mailed or delivered, after such death, to the address shown in this policy shall be sufficient notice to effect cancelation of this policy. 15. Cancelation This policy may be canceled by the insured by surrender thereof to the company or any of its authorized agents or by mailing to the company written notice stating when thereafter the cancelation shall be effective. This policy maybe canceled by the company by mailing to the insured at the address shown in this policy written notice stating when not less than ten days thereafter such can- celation shall be effective. The mailing of notice as aforesaid shall be sufficient proof of notice. The time of the surrender or the effective date and hour of cancelation stated in the notice shall become the end of the policy period. Delivery of such written notice either by the insured or by the company shall be equivalent to mailing. If the insured cancels, unless the manuals in use by the company otherwise provide, earned premium shall be (1) computed in accordance with the cus- tomary short rate table and procedure and (2) not less than the minimum premium stated in the declarations. If the company cancels, earned premium shall be computed pro rata. Premium adjustment may be made at the time cancelation is effected and, if not then made, shall be made as soon as prat• ticable after cancelation becomes effective. The company's check or the check of its representative mailed or delivered as aforesaid shall be a sufficient tender of any refund of premium due to the insured. When the insurance under the workmen's compensation law may not be canceled except in accordance with such law, this condition so far as it applies to the insurance under this policy with respect to such law, is amended to conform to such law. 16. Terms of Policy Conformed to Statute—Coverage A Termsf1of this policy which are in conflict with the provisions of the workmen's compensation law are hereby amended to conform to such law. . 17. Declarations By acceptance of this policy the insured agrees. that the statements in the declarations are his agreements and representations, that this policy is issued in reliance upon the truth of such representations and that this policy embodies all agreements existing between himself and the company or any of its agents relating to this insurance. IN WITNESS WHEREOF, the INSURANCE COMPANY OF NORTH AMERICA has caused this policy to be signed by its President and Secretary at Philadelphia, Pennsylvania, and countersigned on the declarations page by a duly Authorized Agent of the Company. CV HARRY E. YT, Secretary 0 R. COX, President c , ter., �'*d3� 2:'-'s'9. lw• k {i'�a �r.. '� P+ r4 1> 4. . i yi • �, n to 4, r• r i... ��ese�i}R'�•i•1�C A ? `Sea;P.ser.r ns.�:a�•�'�Y2�"Y?iz ,.:�'.r.;.. �''3• ti:� i .}, !: ,-.4c�„ �';`. - l.t. .. ,.- l .-�. a'i?, ..:'ix_ . � . ., - ? . urs... ��1.,-rtx4�'RF:. �3t.r A1W\.e��•.f." i.� sa KirM•�M�. , r?'.