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DEPAR'I'IvIENT OF COrRviUN1TY&,DEVELOPMENT SERVICES
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(909)860-3195 Fax(909)861-3117
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� I HEREBY�FFIRM UNOEN VENALT'OF PERIURV ONE OF THE FOLLOWING OECLARATIONS:
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OF THE WORK FOR NR/ICH THIS PERMIT IS ISSUED. �
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Z I CERTIFY THAT IN THE PERFORMANCE Of TME N^DRN FOR WHICH 7HIS PERMIT IS ISSl1E0,I MECHANICAI
(7 SHALL NOT EMPLOV ANY PERSON IN ANY MANNER SO AS TO BECAME SU&IECT TO THE
� WOFKERS'COM7ENSATION UWS OF CALIFORNIA,AND AGREE THAT IF I SHOUL�BECOME INSPECTION FEE
? SU&IECTTO THE M/ORKERS'COMVENSATIOH FROVISIONS OF SECTION 37ao OF 7HE UiBOR -�
COOE.I SH/�Ll.FORiHWITH COMPLV WITH TMOSE 7ROVISIONS..-- ISSUANCE ��
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DOLUHS(5700.000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN .
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� I CEHTIFV THA71 HAVE REAO THIS APPLICATION AND STATE THAT THE ABOVE INFORMATqN IS CARRECT. TOTAL FE ES
w I AGREE TO COMPLV WITH ALL CITV AND COUNTY OHDINANCES IND STATE LAWS REUTING TO BUIL�ING :I � '
� CANSTRUCTION,ANO HEREBV AU7HORIZE REPRESENTATIVES OF THIS CWN7Y TO ENTER UPON THE
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~ WHITE—DepaAment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�-File Copy,GREEN—Applicant's Copy
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