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' COMMUNITY DEVELOPMENT DEPAi2TMEN`T
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N NESS AN�PROFE5510NS COOE:THE CONTRACTORS LIGENS'e LAW DOES NOT pPPLV TO AN OWNER�F = �
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CC THROUaH HIS OR HER OWN EMPLOVEES,PROVIDEO THAT SUCH IMPROYEMENTS AR[NOi INTENUF.�OR m
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W ❑I,AS OWNER OF THE PROPERTY,AM EXCLUSIYELV CONiHACTING WI7H LIC[NSED CONTRACTORS
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CC 1 NEREBV AFFIRN UNOER PENALTv OF PERJURY THAT IAM LICENSE�UNOER PROVISIONS DF CNAPTER �. ;
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' � i HEREBYAFFIqM UNOER PENALiV OF PERJl1RY ONE OF i1+E FOLLOWING DEQAHATIONS: Z�
O I HAVE AND WILL AAAINTAIN R CERTIFICATE OF CONSENT TO SEIF�INSURE iOF WORKERS' a�
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Q 00 OF THE U80R CODE.FOR THE PERFOFMANCE OF THE WORK FOR WMICH TNIS PERiUIT IS I ���� /'1
ISSUED.MV WORKE 5'CO P�A ENS/�71q�J INSURAHCE CAqRIER AND POLICY NUMBER 0.RE: i CONSTRUCTION ��(�/
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� WORKERS'CONPENSATION LAWS OF CALIFOpNIA,�ND AGF[E THAT IF I SHOUL�BEOOME � INSPECTION FEE
� SUBJECTTO THE WORNERS'CAAIPENSATION PROVISION50:SEC710N 37000F TME UOOfl �L O V
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� W�flNING:FAIURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.ANO SHALL BE ENEAGY P!C
�y SU&IECTANEMPLOVERTOCRIMWI�LPENALTIESANDCIVILFWESl1PTOONEHLINDREDTHWSAND I ENERGYPERMIT I �
OOLLARS(1100.D00),IN 11DDITIIXJ TO TNE COST OF CqNPENSATION,DAMAGES�S PROVIDED FON IN
� SECTION�7oBOFiHEL�BORCODE.INTERE5T.�4�ATTORNEH5FEE5. � RETENTIONFEE: ___ I U
a CONSTRUCTION LENDING AGENCY ! PRE-ALT FEE: "'�
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� I HEREBY AFFIRIA UNOER PENALTV OF PERJURV THAT TNERE IS A CDNSTRUCTION LENDING AGENCY , _
FOR TNE PERFORMANCE OF iHE WORK FOR WHI H THIS PERMIT IS�SSUED�SEC.309�,CIV.G�. � �,,., ,
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� � LENDER'S NAME __ _ I - -
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wICERTIFVTHATIHAVEREADTMSAPGUCATIONANDSTII7ETHATTHEABOVEINFORMATqNISCOfiNECT. TOTAL FEES !�S / •j� l vSll �
� I A6REE TO COMPLY WITH ALL CRV ANO COUNTY ORDINMIGESAND STATE UWS RE:ATINO TO BUIIDING
� CONSTRUCTION,ANO HEREBY AUTHORIZE R[PRESENTFTIYES OF TIi15 CAUNTY TO ENTER UPON THE
Z J1BOVE-MENTIONED PflOPERTY FOR I �PECTON PURPOSES.
0 ��`� �����,/\ COMMENTS__
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EXT. LATHISIDING ' ' POOL FENCING _ � , ___Y__ _
WRL�INSULATION ;� � i POOL FINAL ; �_ ___ _
CEILING INSULATION OFF SITE IMPS.
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bRYtNALL NAILING � � ; DEdiCATiONS _ {
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