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:pt—1999 3: 12PM FROM P. 2 <br /> f <br /> JOB ADDRESS: P76-5 PERMIT#: <br /> fes— I <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 in full force and effect. <br /> License# 4 g 5 1 &!5r /r Expiration Date D7 DI <br /> Date Contractor <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION . <br /> I hereby affirm under penalty of perjury one of the following declarations: <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued.- My workers'compensation insurance carrier <br /> and policy number/are: <br /> Carrier Policy Number <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> ' forthwith comply with those provisions. <br /> Date�`�&I Signature: <br /> _ I WARNING:FAILURE:TO;SECURE•WORKERS';-COMPENSAYI(5N1 ERAGE`IS UNMWFuI:,-AND'SHALLSUGJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES U O ONE HUNDRED THOUSAND DOLLARS <br /> II (100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. <br /> i <br /> i <br /> i <br /> I <br /> i <br /> i <br /> i <br />