Laserfiche WebLink
COLD-�`J'7J I � I i MI'I r nur, .. •- _ <br /> JOB ADDRESS: PERM114t: <br /> LICENSED CONTRACTORS DECLARATION <br /> i hereby affirm that I am licensed under the previsions 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# .S 2 Zoo 'R Expiration Date 4 - 30 - 0 � I <br /> Date (� OD C tractor�p e T f t a 02, �K PII o gj:)L Vt i <br /> Signature <br /> w CARS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pedury one of the following declarations: <br /> E I 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 /> I 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 ZC. C61 Policy Number A <br /> I certify that In the performance of the work ferwhren this permit is issued, I ehall 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 <br /> forthwith comply with those provisions. <br /> Date Signature: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT <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 <br /> THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. <br /> Cl E1.L9-991P-602 cloi 00 OT .add <br />