Laserfiche WebLink
JOB ADDRESS:! SGS $IzeApwA'q..r y1`, fir—44 PERMIT#ti <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provision's of Chapter 9(commencing with Section 7000 of Division' <br /> I.3 of the Business and Professions Code, and my,license is in full force and effect <br /> � t4` <br /> License# � .qG_ ,. Expiration Date. Z <br /> Date 7 Contractor 6uZ /1/AV 6¢r <br /> WORKERS' COMPENSATION DECLARATIONS <br /> 1 <br /> - l <br /> I hereby affirm that I have a certificate-of consent to self-insure, or a certificate of Workers' Compensation <br /> Insurance, or a certified copy thereof(Sec. 3800, Lab.C). <br /> Exp. Date Company - r <br /> ❑ Certified copy is hereby famished, <br /> •❑ Certified copy-is filed with the County Building Inspection Division <br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br /> 4" <br /> (This section need not be completed, if the permit is,for one Hundred dollars (S 100)or less) <br /> 1 certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so <br /> as to become subject to the Workers'Compensation Laws <br /> Date '''Applicant <br /> NOTICE TO APPLICANT: If,after making this Certificate Exemption,you should become subject to the Workers' <br /> Compensation{provisions of the Labor Code,you must Zrthwith comply with such provisions or this permit shall <br /> be deemed revoked. - <br /> P �.L":�`�a.rs i�•�` .i:'-�t. �S' -�_e '«:_^.i,Yc^-z �..,-� .:tiai.�T,c'zz•s'�' -,,!z.,.-..L?::5� Rx,r,.'.- '..._;�y_`.,' m .r..i^:r�`e_..,r;,. -.•.e_.:.-..-,ye�'�-.s. :s..:.- - ..r�3sr._:.:...;..,�,��..<�? <br />