Pinole Building Form – Fill Out and Use This PDF

City of Pinole: Building Permit Application

APPLICANT: PLEASE COMPLETE SHADED AREAS

Pinole City Hall

2131 Pear Street

Pinole, CA 94564

WORKERS’ COMPENSATION DECLARATION

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, 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:

CARRIER:____________________________________________________

POLICY #:____________________________________________________

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 worker’s compensation provisions of Section 3700 of the Labor Code. I shall forthwith comply with those provisions.

Applicant__________________________________________________

Date __________________________________________________

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 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this agency to enter upon the above-mentioned property for inspection purposes. I (We) further agree to save, indemnify and keep harmless the city of Pinole against liabilities, judgments, costs and expenses, which may in any way, accrue against said city in consequence of the granting of this permit and will pay all expenses including attorney’s fees in connection therewith. All work performed by virtue of this permit must conform to plans and specifications and application filed by the owner or his authorized agent with the Building Inspection Division. This permit does not constitute approval of any violation of the above-recited provisions, nor of any state or city ordinance.

Signature _________________________________________________

Date _________________________________________________