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FJOB ADDRESS: <br /> Sty S"I PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code, and my license is <br /> in (full force and effect. <br /> License K 7U 5 Q 27 Expiration Date 3 <br /> Datet2�S�QS _ Contractor i/.on&,)( .^ <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(Ser- 3800, Lab.C). <br /> Exp. Date IOZy 7) Company }e�Q �ulic 'r ey i <br /> 0 Certified copy is hereby furnished <br /> Certified copy is filed with the County Building Inspection Division <br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br /> O'his section need not be completed,if the permit is for one hundred dollars (SIM or less) <br /> I certify that in the performance of the worts for wnirh this permit is issued. I shed not employ any person in any manner so <br /> as to become subject to the Workers'Compensation Laws of CalifOmia. <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 With such provisions or this permit shall <br /> ID:deemed revokes. <br />