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I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect
Worker's Compensation Declaration Warning: Failure to secure workers' compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to one hundred thousand dollars ($100,000) in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest, and attorney's fees.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self-insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
I have and will maintain workers compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are
I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
Declaration Regarding Construction Lending Agency
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code).
By my signature below, I certify to each of the following:
I am the property owner or authorized to act on the property owner's behalf.
I have read this application and the information I have provided is correct.
I agree to comply with all applicable city and county ordinances and state laws relating to building construction.
I authorize representatives of this city or county to enter the above-identified property for inspection purposes.
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