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`OO <br /> JOB ADDRESS: 24111 Mx 1 i,14 w a y 99, _A Cg W%pv PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> 1-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# 612;6 t} Explration Date 6 <br /> Rafe <br /> t0l-)l rcpt Conlrattor l�ti Iti 11 1� rili�+1 C�1vjr0ht404 i <br /> Signature <br /> WORKERS' DUMP NSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalarations. <br /> Q 1 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`mainta n 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 /> N <br /> Carrier t4J Number 1516641-00 <br /> _ Polic y <br /> Q 1 certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner <br /> so as to became subject to the workers'compensation laws of California,and agree That if I should become subject to <br /> the workers'compensation provisions of Section 3700 of the Labor Cade, I shall forthwith comply with those provisions. <br /> Date Applicant <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 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 c?F COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 0.p <br /> THE LABOR CODE,INTEREST,AND ATTORNE'Y'S FEES. <br />