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(909)860-3195Fax(909)861-3117 JUN 17 2002 PRESS
��-��^� 21760 BUILDING PERMIT APPLICATION FIRMLY
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w TURE,PRIOR TO ITS ISSUANCE.ALSO REOUIRES THE APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck
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� I HEREBV AFFIRM UNDER PENALTV OF PERJl1RV ONE OF 7HE FOLLOWING DECLARATIONS: � Z
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w I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION
Q 370o OF THE LABOR CODE.FOR THE PERFORMANCC��OF THE WORK FOR WHICH THIS PERMIT IS
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� WORKERS'COMPENSATION LAWS OF ALIFORNI ,A AG E T AT IF 1 HOULD 8 COME INSPECTION FEE '��� ��'�'.�`` � � I i ] 1
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� SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHU EDTHOUSAND ENERGYPERMIT �
DOLLAHS(f100.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVI�ED FOR IN
� SECTION37080FTHELABORCOOE,INTEREST,ANDATTONNEV'SFEES. RETENTIONFEE: ��r-�--•�-� - -
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� I HEREBV AFFIRM UNDER PENALTY OF PERJURY 7HAT THEFE IS A CONSTRUC710N LENDING AGENCY
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� LENDER'S NAME
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w I AGREE 70 COMPLV WI7H ALL CITV AND COUNTV ORDINANCES AND STATE UWS RELATING TO BUILDWG �
� CANSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUN7Y 70 ENTER UPON 7HE
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