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DEPARTMENT OF COMMU�MTY&DEVELOPMENT SERVICES MA(�' � '� ��('D
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
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w NRE.PRIOR TO ITS ISSUANCE,ALSO REWIRES THE APPLICANT FOR SUCH PEHA/lT TO FILE A SIGNED w P8�10/DBCK
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CENSE LAW(CHAPTER e(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS ANO PqO� POOUSPe
^ FESSIONSCAOE)ORTHATHEORSHEISE%EMPTTHEREFROMANDTHEBASISFORTHEALLEGEDE%EMP� C7
V TION.M1Y VIOLATpN OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SU&lECTS 7HE APPLICANT TO Z Re-Roof
A CML PENALTV OF NOT MORE TNAN FNE HUNDRED DOLLARS(f500),):
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Z WILL DO THE WOR7C,M1D THE STRUCTURE IS NOT INTENOED OR OFFERED FOR SALE(SEC.7a��,BUSI- J �
N NESS AND PROFESSIONS CADE:THE CONTRACTORS LICENSE LAW�OES NOT APPLY TO AN OWNER OF � '
PROPEHTY WHO BUfLDS OR IMPqOVES THEREON,AND WHO DOES SUCH WOHK HIMSELF OR HERSELF OR
Q THROUGH HIS OR HER ONR!EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
� OFFEREDFORSALEIF,HOWEVER,THEBUILDINOORIMPROVEMENTISSOIDWITHINONEVEAROFCOMPLE-
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAP7ER �
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� WORKERS'COMPENSATION DECLARATION Q � �
� I HEREBV AFFIRM UNDER PENALTY OF PERIURY ONE OF THE FOLLOWINO DECLARATIONS: Z
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� I MAVE AND WILL MAINTAIN A CERTIFICATE OF CANSENT TO SELF�INSURE FOR WORKEFiS' _
� COMPENSATqN,AS PROVIDED BV SECTION 37000F THE UBOR CODE,FORTNE PERWRMANCE U
OF 7HE WORK FOR WHICH THIS PERMIT IS ISSUED. W
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QW �HAVE AND WILL MAINTAIN WORNERS'CAMPENSATION INSURANCE,AS FEOUIRED BV SECTION ///���
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' Z �CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOfl WHICH THIS PERMIT IS ISSUED,I MECHANICAL I�J�-�U I 1 I_�� �,
(} SHAIL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECAME SU&IECT TO THE I
(p� ' WORKEFS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE i
SU&IECT TO THE WORKERS'C061PENSATION PROVISIONS OF SECTION 370o OF THE LABOR I
S CrODE.ISHALLFORTHWITHCOMPIVWITHTFIOSEPROVI510NS. ISSUANCE I K � �i /'�I•L �
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� SU&IECTANEMPLOYERTOCRIMWA�PENALTIESANOCNILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT ----
DOLLARS(f100.000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED f-0R IN �—
�• SECTqN37080FhIELA80RCODE,INTEREST,ANDATTORNEV'SFEES. RETENTIONFEE: __ /
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRM UNDER PENALTV OF PERJUFV THAT THERE IS A CONSTRUCTION LENDINO AOENCV � �
FOq THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oY7,qV.CJ.
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� LENDER'S NAME '
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� 1 AGREE TO COMPLV WITH ALL pTV AND COUNTV ORDINANCES ANO STATE UWS REUTINO TO BUILDING 6
� CANSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF iH15 COUNTY TO ENTER UPON THE �� ��
Z ABOVE�MENTIONED P OPERTY FOR INSPECTION PURPOSES. �"'
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= RECPT.NO. PAID BY � VALIDATION
~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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