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, _f�� CITY OF DIp OND BAR _
DEPART�NT OF COMMLJTIITY&DEVELOPMENT SERVICES
a 21660 E:C pley Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRESS �i
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ADDRESS DATE NUMBER #
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� CENSE UW(PUPTER Y(COMMENCWO Wf7H SEC710N 70Do)OF OIVISION 3 OF THE BUSINE55 AND PRO� � Po0USp8
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� ❑I,ASOVMEROFTHEPFOPERTY,ORMVEMPLOVEESWITMWAOESASTHEIRSOLECOMPENSATqN, � CORIRIBfCI01 , �
W�L DO THE WORK,AND THE STRUCNRE IS NO71N7ENDm OR OFFERED FOR SALE(SEC,7at,BUSI- J
� NESS AHD PROfE5910NS COOE:THE CONTMCTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF ?
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� MR700ONTMCTSFORSUp1PRO.lECTSNAh1ACOHTRACTOR(5)LICENSEDPURSUAMTOTMECONTRAC qUANTITY DESCRIPTION
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DATE OWHER �
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1 HEREBV AFFIRM IM�ER PENALTV OF PER1UqV THAT I AM LICENSED UNDEfl PROVISIONS OF CHAP7ER �
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� WORKERS'COMPENSATION DECLAFATION Q � . �
� I HEREBY AFFlRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWIMO DECUM710NS: Z
� _IHAVEMIDWILLMAINTAINACERTIFICATEOFCONSENTTOSELFINSUREFORWORKERS' _ . ,
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Q OF THE WORK FOfi NT/N:h1 THIS PERMR IS ISSUED. �
_I HAVE AND WILL MAIHTAM WORKERS'COMPENSATION INSURANCE,AS REW IRED 0V SECTION ��� , ��
Q 37000F THE LABOR COOE,FOR THE PERFORAI/JlCE OF 7HE WOPoC FOR WHICH THIS PERMIT IS
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(} SHALL NOT EMPLOV ANV PERSON IN ANY MANNER 50 AS TO BECOME SU&IECT TO TME � �-
(ry WOPo(ERS COMPENSATION UWS OF CALIFORNIA,AND AGREE THAT IF I SHOUID BECOME INSPECTION FEE
SU&IECi 70 THE WORI(ERS'C0IAPENSATION PROVISIONS OF SECTKKJ 77000F THE LABOR
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� WARNINO:FAILURE 70 SEW RE WORKERS'COMPENSATqN COVERAOE IS UNLAWFUL,AND SH�LL BE ENERGY P/C
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DOLLARS(f 100.000).IN ADDITION TO THE COST OF COMPENSATION,DMIAGES AS PROVIDED FOR IN
J SECTpN J70B OF TIE LABOR COOE.MTEREST,AND ATTORNEY'S FEES.
pC RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: �
� I HEREBV AFFIRAI UNDER PEN�LTV OF PERIUfiV THAT 7HERE IS A CONSTRUC7ION LENDINO AOENCY
FOR THE PERFOFMANCE OF THE WORK FOR WHICH THIS 7ERMI7IS ISSUED(SEC.90Y7,CIV.C.).
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� LENDER'S NAME .
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I CERTIFV THAT I HAVE R PLICATqN N1D STATE THAT THE ABOVE INFORMATION IS CORRECT. Z
� I AOFEE TO COMPLY WIT ALL C D COUNTV OFi01NMlCES AND STATE UWS RELATINO TO BUILDINO
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