Laserfiche WebLink
08/24/99 09;03 FAX _ Q02 <br /> h <br /> JOB ADDRESS: " _ <br /> LICENSED C©NfRACTORS DECLARATION <br /> 1 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#1 720204 Expiration Date,g o n/n n <br /> Date June 10, 1999 - Contractor Jody A. Vickery <br /> I <br /> Signature� �Jrf� _�—__._, .• _ .. <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalarations:. <br /> I] t 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 /> l 1 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. Col ciPn t,! a1 a Policy Number_ N,lgr- 544559_()4. <br /> D I certify that in the performance of the work for which this perinil 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 subjeci to <br /> the w0 , rs'compen�sattion provisions of Section 3700 of the Labor Code,I shall fgtthwith comply with those provisions. <br /> Date t ' `-1 '7 7Applicant �G c.•1 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED'THOUSAND DOLLARS <br /> (900,000),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 />