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r <br /> JOB ADDRESS:_ 7 c,'asf Sd ,e r- --- PERMIT# <br /> 1 <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am ilcxnsed under the provisions of Chapter 9 (cornmencing with section TOQ() of Division <br /> 1 3 of the Business and Professions Code, and my license is in full force and effecL <br /> License Y 7o 5 q'2--7 Expiration ©ate 1�53 I 2 <br /> 1 Date i2- Connctor �,�I'�o <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 l hereby affirm that I have a rertif"te of mnsant to self-insure, or a ceRificarte of Workers' Compensation <br /> insurance, or a/certified copy thereof(Ser. 3800, Lab.C). <br /> 1 'Exp. Date 1 o/g z-022._ Company igJ <br /> C1 Certified copy is hereby fumished <br /> ' FCertified copy is filed with the County Building Inspection Division <br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br /> ' Mis section need not be completed,if the permit is for one hundred dollars (S100) or less) <br /> I certify that in the performance of the wdrK lot wtveh this permit is issued. t shad not employ any pom6n in any manner so <br /> as to become subject to the Worker:'Compensation Laws of California. <br /> rDate Applicant <br /> NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should become subject to the Workers' <br /> I Compensation provisions of the Labor Code, you must forthwith comply with such provisions or Chia permit shall E <br /> ' <br /> be deemed revalcect. <br /> t <br /> 1 <br /> i <br /> r <br /> r <br /> 1 , <br />