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8-17-1999 2:©aPM oM <br /> . P. 3 <br /> o <br /> JOB ADDRESS: � PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <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# / Expiration Date <br /> Date CQntrac or <br /> i Signature �?�f/GCtX.c Ic <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. i <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, i <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance carrier <br /> and policty� number are: <br /> Carrier r I /�tSK� V( 5 - Policy NumberC �- <br /> i <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 D Signature: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,000), IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF i <br /> THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. <br />