Re: State Farm Insurance-Earthquake Retrofit Form

[Cortney Buletti <http://www.boltdownthebayarea.com/~cortney>]

Hi Robert,

Please find the completed form attached.  Let us know
if you need further assistance.

Take care and enjoy your weekend!

Cortney Buletti EBB Dashboard Manager

Bolt Down The Bay Area 707.582.0448

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CEA EARTHQUAKE INSURANCE - DWELLING RETROFIT VERIFICATION FORM
PARTICIPATING INSURER AND POLICYHOLDER INFORMATION
CEA Participating Insurance Company:

CEA Policy #:

Name of Policyholder:

Phone #:

Robert

my-Oakland-voicemail-number

Address listed on the CEA policy and inspected:
Street:

E-mail:

 .

http://dummy.us.eu.org/robert

City

ZIP Code:

Date Inspected

where-I-live

6/19/2024

DWELLING INFORMATION
Year of dwelling construction:

1936

Is the dwelling a wood frame single family home (1 -4 attached residential 
units)?
Is the dwelling anchored to the foundation in accordance with the
applicable building codes, as determined by an inspection conducted in
accordance with the Ca Earthquake Authority (CEA) Dwelling
Retrofit Verification (DRV) Requirements.

Is the dwelling on a raised or other foundation type?* (A house constructed on 
a slab foundation does not qualify for discount.)

✔

Yes

No

Yes

No

✔

Yes

No

Does the dwelling have cripple walls?
If yes, are the cripple walls braced in accordance with applicable
building codes, as determined by an inspection conducted in accordance
with the CEA DRV Requirements?

Is the dwelling on a post-and-pier or post-and-beam foundation?
If yes, is the dwelling on the post-and-pier or post-and-beam foundation
modified in accordance with applicable building codes, as determined by an
inspection conducted in accordance with the CEA DRV Requirements?

Is the dwelling on a unreinforced masonry-brick, concrete block, or stone 
foundation?

If yes, is the dwelling on the unreinforced masonry-brick, concrete block,
or stone foundation modified in accordance with applicable building codes,
as determined by an inspection conducted in accordance with the CEA DRV
Requirements?

Yes

✔

Yes

No

Yes

✔

Is the water heater secured to the building frame in accordance with
Guidelines for Earthquake Bracing Residential Water Heaters (Ca
Department of General Services, Division of the State Architect)?

✔

✔

No

Yes

No

Yes

No

Yes

No

Tankless water heater shall be installed in accordance with manufacturer's 
requirements.

* Definitions of foundation types are on the CEA website: 
www.earthquakeauthority.com Insurance Policies - Premium Discounts

CIVIL OR STRUCTURAL ENGINEER or LICENSED CONTRACTOR INFORMATION

✔ General Building Contractor
Civil or Structural Engineer

General Building Contractor/Civil or Structural Engineer License Number:

801910

Contractor or Engineering Business Name:

Was this entity the engineer or contractor of record for this

Bolt Down the Bay Area / Warner Custom Homes inc retrofit work?

✔

Address:

1424 Cunningham Rd. Sebastopol, CA 95472
Contractor/Engineer Name:

Phone #:

Date:

Sean K Warner - WCH, Inc.

707 477 3347

6/25/2024

Contractor/Engineer Signature:

Professional Title or Designation, if any:

General Contractor / B License

By signing above, I certify that I have inspected the property in
accordance with the provisions of CEA DRV Requirements and I have answered
the questions above to the best of my knowledge, for the purpose of
verifying whether the seismic retrofit described above has been completed
in accordance with applicable building codes. My inspection, and my
signature above, are not to be deemed an evaluation, approval, or
endorsement of the quality or workmanship of the retrofit work, nor a
warranty, guarantee, or endorsement, or opinion of the safety or
performance of the retrofit or of the property in the event of an
earthquake.

BRACE + BOLT PROGRAM RETROFIT VERIFICATION
B+B Application Number

Approved Date:

Verification Number:

PROCESSING

To obtain the discount, this CEA Earthquake Insurance Dwelling Retrofit
Verification form must be completed requiring a signature (by a licensed
general contractor or a civil or structural engineer) or a valid Brace +
Bolt verification number listed on the form. Send the completed form to
your insurance agent/homeowners insurance company for processing.

CEADRV 01-2019 Edition

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