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JOB ADD"RESS. � 9".�. C 1,g rr e ir."Wad Sto G kt h PERMIT#:. d <br /> ' DECLARATION <br /> LICENSED <br /> CONTRACTORS: <br /> I 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+51 # 65 G 40-+ Expiration Date 110-1 <br /> Date �I�(o l Zcao Contractor Ore % S i tw114C, <br /> Signature <br /> WORKERS' 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 Labor Code, for the performance of the work for which this permit is issued. <br /> 0 i 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 /> Carrier Eqq E Policy Number 4 S 00002- 5 <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'compensation laws of California, and agree that if I should become subject to <br /> the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. <br /> Date Applicant <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> l AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,000), 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 /> I <br />