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J WARNING FAILURE TO SECURE WORKERS'COMPENSATION CA RAGE IS UNLAWFUL,AND SMALL BE ENERGY P/C
� SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCINLFINESUPTOONEHUNDREDTHWSAND ENERGYPERMIT
DOLURS(i100,000).IN ADDITiON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTpN 370!OF THE LABOR CODE,MTEREST,ANDATTORNEV'S FEES.
oC RETENTION FEE: '•����
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBVAFFIqM UNDER PENALTV OF PERIURY THAT THERE IS ACONSTRUCTION LENDING AGENCV
FOR TFIE VERFOFMANCE OF 7HE WORN FOR WHICH 7N15 PERMIT IS ISSUED(SEC.9ov7,CIV.C.).
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� LENDER'S NAME
�- LENDER'SADDRESS
� I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATpN IS CARRECT. TOTAL FEES S� • �' �p.. J�
w I AGREE TO CAMPLV N7TH ALL CT'AND COUNTY ORDINANCES AND STATE UWS RELATINO TO BUILDINC
� CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS CWN7Y TO ENfER UPON THE '
ZABOVE-MEMIONED 7ROPE TY FOR INSPECTION PURPQSES.
p �� COMMENTS
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m PERMI77EE NAME(PRI � �
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� SIGNATURE OF PERMITfEE DA
= RECPT.NO., PAID BY � a0 VALIDATION
~ WHITE—De artment Co YELLOW�inance Co PINK—Assessor Co CaOLDENROD--File Co GREEN—
0 PY. PY. PY, py, ApPlicant's Copy
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