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DEpARTMENT OF COMMUNITY & DEVELOPMENT SERVICES PRESS
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(909) 860-3195 Fax (909) 86 �r rr drrnlu
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OWNER -BUILDER DECLARATION
LICENSED CONTRACTORS DECLARATION
1 HEREBYAFARM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROWStONS OF CHAPTER
P (COMMENCING WITH SECTION TDWI OF DIVISION 3 OF THE BUSINESSANO PROFESSIONS COOE. WD
MY LICENSE I31N FULL FORCEAND EFFEECT. ^/
LICENSE CLASS �� LTC. NO. 77 0�2 75___
DATE,T CONTRACTOR
1
WORKER 'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PETUURY ONE OF THE FOLLOWING DECLARATIONS:
,INANE ANTJ WIL MMAIN ACERTFICAtE Of CONSENTTO SELFINSURE FOR WORKERS'
COMPEN ,ASPROVIDFC 9YSECTION'='THELABOR CO OE, FOR THEPERFORMANCE
OF RK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERG• COMPENSATION IN501AN0E• AS REQUIRED BY SECTION
3—OF THE :AROR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
I55JED_MYwnAKPP5'COMPENSA INSU NLE RFtlER WD POLICY NUMBERARE
POLICYNUMBER
C"HIS SECTION NEED NOT BE COMPETED OF THE PERMIT IS FOR ME NADPEI) 11A (V N)OR LESS}
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IS5UEO. I
SHALT. NOT EMPLOYANY PERSON IN ANY MANNER SO AS TO BECOME SUWFCT TO THE
GOQ 1/S(H�A:A. /O�)WfHWiTH COMPLY WI Tl1 OVISIONS,
DATE, ` APPLICANT.
WARNING: FALURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL8E
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (6+oo.BW ). IN ADDITION TO THE COSTOF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION WOO OF THE LABOR CODE, INTERFST AND ATTORNEY' FEES.
CONSTRUCTION LENDING AGENCY
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FDA THE PERFORMANCE OF THE WORK FOR WHICH THI5 PERMIT* FS5VEO (SEC. 30W. CIV C.),
LENDERS NAME �—
LENDER'S ApORESS
I CERTIFY THAT I RAVE READ THIS APPLICATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT.
IAGREE TO COMPLY WHN ALL CITY AND COUNTY OR D INANC AND STATE LAWS RELATING TO SUROM'G
CONSTRUCTION, AND NFFIC. 11HOHUE REPRESENTATIY OF iNf3 COUNTY iO ENTEfl UPON THE
A80YE`MENTIONEDPROPERTYFORINSPEC PURPOS
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RETENTION FEE:
PRE-ALT FEE
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CITY OF DMMOND BAR
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