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, �,�� CITY OF DIAMOND BAx
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. '�', BUILDING PERMTl'APPLICATION �""-- FIRMLY
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� _I HAVE AND WILL MAINTAIN CERTIFICAT F CONSENT TO SELF-INSURE FOR WOR)(ERS' ¢ .
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� COAIPENSATION,AS PRO DED BV SEC 3700 OF THE U180R CODE,FOR THE PERFORMANCE U
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_I HAVE AND WILL MAI AIN WORKE 'CAMPENSATION INSURANCE,AS REWIRED BV SECTqN
. O 37000F THE LABOR E,f-0R PERFORMANCE OF THE WORK FOR WHICH THIS PEflM1T IS ' '
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(/� WORKE COMPEN ATIONUWSOFCALIFORNIA AOREETHATIFISHWLDBECOME INSPECTIONFEE J
SUBJEC7 tO THE RKERS'COMPENSATqN VR0 S OF SEC710N 3700 0F THE LABOR /
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p DATE: �� D APPLICANT: ` SMIP '
J WARNWO:FAILURE T SECURE WORKERS'CAMPENSATION COVERAOE IS UNUWFUL,M1D SHALLBE ENERGY P/C • �
� SUBJECT/WEMPL ERTOCRIMINAIPENALTIESANDCMLFINESUPTOONEHUNDRED1T70U5AND ENERGYPERMIT ' ��
DOLIMS(i10o. ,W ADDITION TO THE C0.ST OF COMPENSATION,DAMAOES AS PROVIDED FOR IN
J SECTION 37a!O E UBOR CODE,INTERES7,AND ATTORNEI"5 FEES. � • � - �
OC RETENTION FEE:
O � CONSTRUCTION LENDING AGENCY PRE•A F E: /
� I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT 7HERE IS�CONSTRUCTION LENDINO AOENCY �
F-0R hiE PERFORMANCE OF THE WORK FOR WHICN THIS PERMIT IS ISSUED(SEC.70D7,CIV.C.�.
' � LENDER'SNAME • �
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� LENDER5ADORESS
� I CERTIFY THAT I HAVE READ THIS MPLICATION AND STATE 7HAT TME ABOVE WFORA/ATpN IS CORRECT. TOTAL FE ES � I �
� I A(3REE TO COMPLY WITH ALL CT'AND COUNTY ORDINANCES AND STATE LAWS REI.ATINO TO BUILDINO � � % O
� CONSTRUCTION,AND HEREBV AUTFIORIZE REPRESEN7ATIVES OF TNIS COUNTY TO ENTER UPON THE �
Z ABOVE-MENTIONED PROPERTY F-0P INSPECTION PURPOSES. COMMENTS �
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SHOWEFi/TUB TEST POOL ELECTRIC
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DRYWAL.L PVAIUNG DEDICATIONS �
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FiNAL ELECTRIC DEV. FEES PAID �
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