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01/31/2002 11 51 2094683433 FIFTH FLOOR PAGE 03 <br /> re W <br /> JOB ADDRESS: 1333 , R whY PERMIT#: <br /> RWID4 LOCO-TION) <br /> LICENSED CONTRACTORS DECLARATION <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# Expiration Date I Dl";A,- i d'ry <br /> Date V/ 07-- ntra o <br /> Signature aj <br /> ORKERS' COMPENSATION DECLARATION <br /> MI hereby affirm under penalty of penury one of the following decalarations <br /> 0 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 o1 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 /> Carrier a- ' &:�411---�- Policy Number A.)C- 09. /-S70(O 0 <br /> O 1 certify thal 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'compensaI la f California, and agree that if I should become subject to <br /> the workers'compensation provisions of' ection 3700 the abor Code, I shall rthwith ply with those provisions <br /> Date Applicant <br /> WARNING FAILURE TO SECURE WORKERS'COMPENSATION C FERAGE IS UNLAWFUL_,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES BJP 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 />