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21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
"''�.��y�' BUILDING PERMIT APPLICATION FIRMLY
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Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7oa4,BU51- J COrtIR18fClel �
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� 1 HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER �
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� WORKERS'COMPENSATION DECLARATION Q
� 1 HEREBY AFFIRM UNDER PENALTV OF PERJURV ONE OF 7HE FOLLOWING DECLARATIONS: Z
� IHAVEANDWILLMAMTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORVXIRKERS' a
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¢ CAMPENSATION,AS PfiOVIDED BY SECTION 77000F THE LABOR CODE,FOPTHE PERFOflMANCE W
Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
w 1 HAVE AND WILI MAMTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION /
Q 37000F THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH 7HIS PERMIT IS ��'\]�
ISSUED.MY WORKERS'CAMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION `J�)
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�J SHALL NOT EMPLOV ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE •��
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE 7HA71F I SHOULD BECOME INSPECTION FEE - .
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR Q
� CODE,ISHALLFORTHWITHCOMPLYWITHTHOSEPROVISIONS. ISSUANCE a O�
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p DATE: APPLICANT:
J WARNING FAILURE TO SECURE WORKEFS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE ENEFGY P/C
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DOLLARS(f 7 00.000),IN ADDITION TO THE COST OF COMPENSA710N,DAMAGES AS PROVIDED FOR IN
� SECTION 3708 OF THE LABOF CODE,INTEREST,AND A7TORNEY'S FEES. flETENTION FEE: •
a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: c •
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� I HEREBV AFFIRM UNDER PENALTV OF PERJURY THATTHERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.�.
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� LENDER'S NAME
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� I CERTIFV THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
w I A�REE TO COMPLY WITH ALL CITY AND COUNTV ORDINANCES AND STATE L4WS RELATWG TO BUILDING
� CANSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTEfi UPON THE
� ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. �/ '
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~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicant's Copy
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