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1 <br /> ' F.J.B A,Dc,RESS:� � - r PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am iicensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br /> r3 of the Business and professions Code, and my iicense is in fu11 force and effect. <br /> License * 7051'2-7 Expiration Date S 3 / s9�7 <br /> ' Date 12 Contractor 1 11,-o 4 � r`-., r _ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby aMrm that I have a certificate of consent to setf-insure, or a certffi=e of Workers' Compensation <br /> Insurance, or a certified copy thereof(Sec. 3800, Lab,C). <br /> Exp, Date 10 Company �+�'c <br /> Ci Certified copy is hereby fumished <br /> FCertified copy is flied with the County Building Inspection Division <br /> CERTIFICATE OF EXFMP'TION FROM WORKERS' COMP ENSATIQN INSURANCE <br /> (This section need not be completed, if the permit is for one hundred dollars($100) or less) <br /> I certify that in the perforrncance of the w aru for which this permit is issued, I shoo not employ any person In any manner So <br /> as to becorne subject to the WorkQrs'Cnmpensatian Laws of California. <br /> ' Date Appflcant <br /> NOTICS TO APPUCANT: If. after making this Certif tate of Exemption,you shouid 'become subject to the Workers' <br /> 1 Compensation provisions of the Labor Code, you must forthwith comply with such provisions yr this permit*hall <br /> be deemed revpKecL <br /> 1 <br />