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08/11/1999 14.37 00000000800 i PAGE 02 <br /> rf. <br /> JOB ADDRESS: PERiMIT#; <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I*m**A&Wundtr the provisions of ChaPW 9(Cornmenaing With 34,0210M 700Q of Divis+on <br /> 3 of the ausinese and Professions Code.and any.fileente tJ in OA force and effect r <br /> 1:�cense Expiration Day <br /> DateConrraccar <br /> W0RKF.RS' CdMPENSAroN DECLARATIO14 <br /> I hereby atRrrn Mali I have a caffoa l of consent to wit-iitsurd. or-a cern, =w of workersGompan88*M <br /> InsuravA, ora cenffied Copy thearraf(Sec.38011.Leb-C� <br /> Exp, Date Company <br /> D Certified 'copy is hereby furnished <br /> ❑Certified Dopy ,s iced Vitt+ the County Buddit inspection Division <br /> CERTIVICATE OF ExEMPTION FROM WORKERX COMPENSATV4 INSURANCE <br /> s tar one h ftdred dopers($1OM of less) it espy�raanr+er so <br /> r <br /> (This wation road no be=70k d. the per"�t's <br /> I cantly mot in the par offnar"of tht work for which out pwrnh a aswd•I sw rat Y am Peter <br /> as to become subject to the Women,COM IWaatror Laws of Cailhornia. . <br /> Date Apt�icat+t <br /> NOTICE TO APPLICANT: if,after mAkI gag thk CV00Cale Of exwnptian,you should b&c*m*subject tD fru Workers' <br /> compensation provisions of the Labor Code,you must forthwith cprr►pir with such pro�atioM <br /> or this pear's!sties <br /> tae deemed rrvbk6d. <br /> i <br />