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O i <br /> JOB ADDRESS. �7 (,JW Soar PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm Mat I am Itc ensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code. and my ri(-,ense is in full fond and effect. <br /> License + 7050tL7 Expiration Date SA 14�i_ <br /> Date 12 - _ Contractor <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers' Compensation <br /> Insurance, or a certified copy thereof(SCC. 3800, Lab.C). <br /> Exp, Date IO/yLo?)._ _ Company <br /> CCl Certified copy is hereby furnished <br /> FCertified copy is filed with the County Building Inspection Division <br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSA'T'ION INSURANCE <br /> Mis section need not be wrnpieted,if the permit is for one hundred dollars($1GM or less) <br /> I certify that u7 the perfortstance of the work Torwtuch thts permit is is3ued,I shall ri*t employ any parson En any manner so <br /> as to become subject to the Workarn'Compensation Laws of Wrfomia. <br /> Date Applicant <br /> NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should become subject to the Workers' <br /> Compensation provisions of the Labor Code,you must forthwith comply wltn such previsions or this permit shall <br /> be deemed revokes. <br />