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L <br /> rr I <br /> JOB ADDRESS: PERMIT#: <br /> E <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, -� 7 <br /> License# l W� Expiration Date I � W 1 <br /> Date c7 Co for i1 �1 <br /> 'Signature <br /> WQ ERS' COMPENSATION DECLARATION <br /> 4 <br /> I hereby affirm under penalty of perjury one of the following;declarations: <br /> 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. I <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, b <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance carrier <br /> and policy number are: <br /> r y II r i' <br /> Carrier0 S( Policy,Number <br /> I certify that in the performance of the work for which this.permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers`compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall I <br /> forthwith comply with those provisions. <br /> i <br /> Date Signature: 4 <br /> I <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT j <br /> 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 j <br /> Tt{E LABOR CODE,INTEREST,AND-ATYORNFY'S FEES- <br /> I 'd <br /> EES.ld IN02i9 WVVV'8 6661-9Z--L i <br />