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JOB ADDRESS: J��7� rd rCef PERMIT#: <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 <br /> /�J,e 11136) /?4-1Date Contractor A l/eWe-Qd- C7�FJ�Kyf/ 1 ✓ C. <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers' Compensation <br /> Insurance, or a certified copy thereof(Sec. 3800, Lab.C). <br /> Exp. Date M ! Company S /"VA-D - <br /> 0 Certified copy is hereby furnished <br /> W�Certified copy is filed with the County Building Inspection Division <br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br /> (This section need not be completed,if the permit is for one hundred dollars (5100) or less) <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so <br /> as to become subject to the Workers' Compensation Laws of California. <br /> Date Applicant <br /> NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers' <br /> Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall <br /> be deemed revoked. <br />