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Grant Street <br /> f J Jpp ADDRESS : 749 E . Charter W ; Sky Sto . cton _ -- PERMIT#; <br /> LICENSED CONTRACTORS DECLARATION <br /> i I <br /> I hereby tiff irm that I am licensed under the pro�!sions of Chapter 9 fcor, :mencing with Section 7000 of olvislor <br /> 3 of the Eluainess and Profeasions Code. and my !iaenae Is in fun force a id effect. I <br /> License W, 073504.._.._� =xpirat ionDate 6 / "1001 <br /> Cate Contractor xontier D :^ illi_ ng <br /> Signature <br /> 0 ERS' 1447N DECLARATION <br /> i <br /> I h3r8by 3fFirm under pet+alty of peNury the following doolarations; i <br /> i I have and will maintain a certifitAta of consent to self insure for Workers' Compensation, as provided for by <br /> Seetion 3700 of the Labor Code, far tha performance of the work for whioh this pormit is issued, <br /> I have and wi!I maintain workers' compensation insurance, a8 required by Section 3700 of the Lacw Code , <br /> for thea performance of the work for which tills permit is issued. my workers' compensation in3w once carrier <br /> and pogcy rumber ars' <br /> j Carrl2r 5teta Fund Pc+icy Number 1180513 � <br /> I <br /> I certify that in the performance of the work for which this permit is Issued, I Shall nut employ any person in <br /> any rtfanner so as to hacoma 3ubi4ct to the workers' Comp2n52t10n laws of California, and agree that if 1 <br /> should pecome subject to the workers compensation provisions of Seation 3700 of the Labor Code , I Shall ' <br /> forthwith comply With thoee ,hrovisicns. <br /> Gate �8 / = 0 / 00 3iynature: s r_ <br /> WARNING: FAILURE. TO SECUAF WORKERS' C0MPE4N$ATl8N tOVERAGE IU AWr A,NO 5 ALL SUBJ ECT <br /> AN 6Stapi_OVEi? TQ GR!NIINAL PENALTIES AND Clvtt PkNEB UP TO pNe" litJN D TH Lf5ANC LLARS <br /> 11 "00.000.1 , IN ADDITION TA THE COST OF COMPENSATION. DAMAGES AS PROVIDED Jj;CR I' t CSICN 370A OF <br /> THE LAIIQR CODE. INTEREST. AND ATTORNEY'S FEES . <br />