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CENSE UW(CHAVTER p(COMMENCWO WITH SECTION 7000)OF DIVISION 3 0F THE BUSINESS AND PR0- POOUSPO
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V TION.ANV VqLAT10N OF SECTION 7031.5 BV ANV A7PLICANT FOq A PERMIT SU&lECTS hIE APPLICANT TO Z Re-Roof �
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� ❑I.ASONTJEROFTHEPROPERTY,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � CORIRIefC18I -
� Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFEFED FOR S/�LE(SEC.70a,BU51� J
N NESS AND PROFESSIONS CADE:TME CONTRACTORS UCENSE LAW DOES NOT APPLV TO AN OWNER OF �
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� I HEREBY AFFIRM UNDEFi PENALTY OF PERIURY THAT I MI LICENSED UNDER PROVISIONS OF CHAPTER �
� e(COMMENqNO WITH SECTqN 7a00)OF DNISION 3 OF THE BUSINE55 AND PROFESSIONS CODE.AND Z
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� I HEREBV AFFIRM UNDER PENALTY OF PERJUHI'ONE OF THE FOLLOW WO DECLARATqNS: Z
� I HAVE AND WILL M/UNTAIN A CERTIFICATE OF CONSEM TO SELF-INSURE FOR WORKERS' _
� � COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE U
Q OF THE WORK FOR WHICFI THIS PERMIT IS ISSUED. � ,
W _I HAVE AND WILL MAIMAIN WORKERS'COMPENSATqN INSURANCE,AS REOUIRED BV SECTION
Q 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ��Gj ��
ISSUED.MV WORKERS'COA/PENSATqN INSURMlCE ARRIER AND PoLICV NUMBER ARE: CONSTRUCTION ��
� CARFIER � PLAN REVIEW
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Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C.'} SHALL NOT EMPLOY ANV PERSON IN ANV MANNER 50 AS TO BECAME SU&IECT TO THE
(/� WORI(ERS'COMPENSATION LAWS OF CALIF-0RNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE
SU&IECT TO THE WORKERS'CAMPENSATION PROVISIONS OF SECTqN 7]OOOF THE LABOR
= cooE,i HALLFpRTHWITHCOMPLVWITHTHOSEPROVIS10N5. ISSUANCE �
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J WAANINO:FAI TO SECURE WORKERS'COMPENSATIO OV R E I UNUWFUL,AND SHALL BE ENERGY P/C
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� SU&IECTANE PIOVERTOCRIMINALPENALTIESANDCML INESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
D�LLARS(St ,000�,W ADDITON TO THE CQST OF fAMPENSATION,DAMAGES AS PROVIDED FOR IN
� SECTION 37aE OFTHE LABOR CODE,MTEREST,ANDATfORNEV'S FEES. RETENTION FEE: ♦
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRAI UNOER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCV �
FOF THE PERFORMANCE OF THE WORN FOR WHICN TMIS PERMIT IS ISSUED(SEC.3087,CIV.C.�.
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� LENDER'S NAAIE
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w ICERTIFVTHATIHAVEREADTHISAPPLICATlONANDSTATETHATTHEABOVEINFORMATqNISCARRECT. TOTAL FEES 1/�.. //
� I AGREE TO COMPLV WfTH ALL CITY AND COUNTV ORDINANCES AND STATE LAWS RELATINO TO BUILDIN6 l ��f/� ��
� CONSTRUCTION,AND HEREBV AUTVqRIZE REPRESENTATIVES OF THIS COUNTV TO EMER UPON THE
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~ HITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicant's Copy
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