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P 0 R rr- S� At 0 <br /> FJOIB3ADDIRESS: 1333 £. <br /> WAY <br /> PERMIT#: <br /> I,n+l rtes :.i ��'At10N) <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed der the provisions 1 cense Shapter 9 force and effect.(commencing with Section 7000 of Division <br /> 3 of the Business and Professionsff <br /> p <br /> License# <br /> Expiration Date <br /> Date l 17 0 7_1 ontra o <br /> 1 <br /> Signature <br /> ORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following 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 tabor 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 /> for the performance of the work for which this permit is issued. My workers'compensation insurance carrier <br /> and policy number are- <br /> 11111 f <br /> Carrier 1 11-11 <br /> Q �olicy Number �C_ <br /> O 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 become subject to the workers' compensatR'_ <br /> (California, and agree that if 1 should become subject to <br /> the workers'compensation provisions of Section 37abor Code, l shall r-thwith ply with those provisions. <br /> Date ` Applicant <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION C ERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (ioo,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. <br />