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JOB ADDRESS: 8 kO Vlir Or 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 # C-S 7 Expiration Date f 43/ 400 <br /> Date Contractor (rE�7� ���lln�. �i�✓ i//� <br /> Signature Ov , ) w2t are_ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing decalarations: <br /> ❑ 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 /> have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code, <br /> or the performance of the work for which this permit is issued. My workers' compensation insurance carrier <br /> and Policy number are: � <br /> Carner, ,\�,\S C r-SC-Q7n Policy Number�k)m I�V�( f`t Z 14 <br /> ❑ 1 certify that in the oerforrpance of the work forwhirh this permit is issued. I shall not employ any person in any manner <br /> so as t0 become subject to the workers =mpensation laws of California, and agree that if I should become subject to <br /> the workers' compensation provisions of Section 3700 of the'�bor de. I shall forthwith comply with those provisions. <br /> Date POS! 9 g Applicant�, <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 D0LLARS <br /> (100,000), IN AODITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />