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LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the previsions of Chapter 9 (commencing with Section 7000 of Division <br /> of the Business and Professions Code, and my license is in full force and effect, <br /> License Expiration Date <br /> Cate 'zoCont c rt tt f P t t« t t t° t t CEt " t. <br /> Signature <br /> WORKERS' COMPE SATIONDECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalaraticans: <br /> l f have and will maintain a certificate of consent to seff-insure forworkers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued:, <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers*compensation insurance carrier <br /> and policy number are. <br /> Carrier Policy Number <br /> 1 certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner <br /> so as to become subject to the workers*compensation laves of California,and agree that if t should become subject to <br /> the workers*compensation provisions of Sections 3700 of the Labor Code, I shall forthwith comply with those provisions. <br /> Date Applicant <br /> WARMING. FAILURE TO SECURE ORKERS'COMPENSATION COVERAGE IS UNLAWFUL,FI L,AND SHALL.SUBJECT <br /> N EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> fg , ggl,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE,E INTEREST,AND ATTORNEY'S FEES. <br />