HomeMy WebLinkAbout15924 (22) ��,:;�� __1,�� CITY OF DIAMOND BAbt
� DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES
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BUILDING PERMIT APPLICATION JUN 1 FIRMLY
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� WORKERS'COMPENSATION DECLAAATION I �� Q
� I HEREBV AFFIRM UNDER PENALTV OF PERRIM ONE OFTIIE FOLLOVJINa DEClARA710NS: Z
� _I HAVE AND WILL MARITAIN A CEfiTIFlCATE OF CONSEM TO SELF•INSURE FOR WORKERS' a �
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COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LA80R CODE,FOR THE PEFFORMNJCE U
Q OFTHEWORKWRNRIICHTHISPERAlITI5155UED. �
_I HAVE AND WILL AWNTAIN WORKER9'COMPENSATKKJ INSURANCE,AS REOUIRED BV SECTION r
� Q 97000F THE LABOR COOE.FOH THE PEHFORMANCE OF THE WORK FOR WHICH THIS PERAIR IS 1�
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W I CEfiTIFV THAT IN h1E PERFORMANCE OF THE W�DRI(FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL
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(� SNALL NOT EMPLOV ANY PERSON W ANY MMlNER 50 AS TO BECOME SU&IECT TO THE
� WORKERS'COMPENSATIONLAWSOFCAI.IFORNIA,ANDA4REETHATIFISHOUIDBECOME INSPECTIONFEE.
S SUBJECT TO THE WORKERS'COMPENSATION PFOVISIONS OF SECTION 370o OF THE UBOR
cooE,i Foanawirr�coM�v Nnn�nrose Paov�saNs. ISSUANCE /�
p DATE:,����"- •�D"RPPLICANT. SMIP �1� .
� WARHINO:FAILUHE TO SECURE WORI(EFS'CAMPENSATKKJ COVERAQE IS UNLAWFUL,M10 SHALL B ENERGY P/C �
� SUBJECTANEMPLOYERTOCRIMWALPENALTIESANDCIVILFWESUPTOONEMUNDREDTFKKISAND ENERGYPERMIT �
DOIURS(i100,000).IN ADD�TION TO THE CAST OF CAMPENSATION,DMIAOES AS PROVIDED FOR IN ��J
J SECTION 37o80F THE LABOR CODE.INTEREST,AND ATfORNEV'S FEES. RETENTION FEE: +E .� �F�g.P/ll�
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OCONSTRUCTION LENDING AGENCY pqE-ALT FEE: B�.T1�LI� A 11i��n e.�....�_
� I HEREBV AFFIPM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDINa AOENCV �
� FOR hfE PERFORMANCE OF 7HE WOiU(FOR WHICH TMIS PERMIT IS ISSUED(SEC.3087,CIV.C.). . -
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� LENDER'S NMIE
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w I CERTIFY THAT I HAVE READ THIS APPLICATION AND 9TATE THAT TNE ABOVE WFORMATION IS CORRECT. TOTAL FE ES �� ` �
� I AOREE TO COMPLV WITH ALl CT'AND COUNTV ORDINANCES AND STATE UWS REUTINO TO BUILDINO
CONSTRUCTION.AND HEREBY AUTMORIZE REPFESENTATIVES OF THIS COUNTV TO EMER UPON THE
S� ABOVEMENTIONED PHOPERTY FOR INSPECTqN PURPOSES. COMMENTS
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� RECPT.NO. PAID BY VALIDATION
WHITE--0ep ment Copy,YELLOW�Inence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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ROOF SHEATFtING �� �v �8 FT, BOND BEAM �
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