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• • <br /> JOB ADDRESS:' C61hr "� PERMIT#: <br /> l LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am 11ransed under the provisions of Chaptar 9 (commencing with Section 7000 of Division <br /> 3 of the Susine= and Professions Code, and my ricense is in full form and effect. <br /> License # 70 S q 2-7Expiration Date 3 r <br /> Date 12� qui Contractor <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm that I have a certificate of consent to setE-insure, or a certificate of Workers' Compensation <br /> Insuranco, or a certified copy thereof(Sec. 3800, Lab.0), <br /> Exp. Date d 0 Company, 14_�Xj_ <br /> Q Certified ropy is hereby furnished <br /> Certified copy is flied with the County Building inspection Division <br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br /> (This section need not be completed. If the permit is for one hundred dollars(S1Cq or less) <br /> I certtfy that in the performance of the work for wrt:W this permit is issued, I shalt not employ any person in any manner so <br /> as to become subject to the Woricam'Compensation Laws of California. <br /> Date Appllcant <br /> ?40TICE TO APPLICANT: If,after making tis Certificate of Exemption,you should become subject to the Workers' <br /> Compensation provisions of the Labor Code,you must forthwith comply witrs such prorisiQn s w this permit shall <br /> be deemed revolted. <br />