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JOB ADDRESS: —�7 ( Jcsf 56Mr--, _ PER.MIT#: <br /> LICEN5ED CONTRACTORS DECLARATION <br /> 4 <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 i'tcense is m/full force and ef(ecL <br /> License t Expiration Hate x/_3116-D <br /> Date !2 Contractor Vro 1C11 I', e_ <br /> WORKERS' COMPENSATION (DECLARATION <br /> I hereby atnrm that I have a certifrrato of consent to se#f-insure, or a cer'Kcate of Workers' Compensation <br /> Insurance, or a Certified copy thereof(Sec. 3800, Lab-C). <br /> Exp. OateP D _f Q �. company l 10,�gj 'r S�,raA-f o _ <br /> C1 Certified cosy is hereby furniished <br /> Certified copy is flied with the County Building Inspection Division <br /> C1~RTIFICA7E OF EXEMPTION FROM WORKERS' COMPENSA'T'ION INSURANCE <br /> (]'his section need not be completed,if the permit is for one hundred doltars ($100) or less) <br /> I certify that in the performance of the worK Tor wfrich thfa permit is '%sued. I shelf not employ any ¢�arsnn in any manner Sd <br /> as to becorrme subject to the Workers'Cempensafiari Laws of Car'rfornia. <br /> Date Appncam <br /> NOTICE TO APPLICANT: If. after making this Certifcrate of Exemption,you should become subject to the Workers' <br /> Compensation provisions of the Labor Code, you mus:forthwith comply with succi pruvisiorns or this permit stall <br /> be deemed revoked. <br />