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'T JOB ADDRESS: _��-S 6r,1� L���c , PE�MIT : <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 # c7 Expiration Date <br /> / <br /> Date C Contractor <br /> 1 <br /> i Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: r <br /> 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 f <br /> and policy number are: <br /> Carrier ocfSl.0.�1c�L2tiH�ct.� Policy Number 17f <br /> I certify that in the performance of the work for which this permit is issued. I shall not employ any person in F <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. 1 shall <br /> forthwith comply with those provisions, <br /> Date Signature: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENISATION 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 i <br /> THE LABOR CODE, INTEREST, AND ATT'ORNEY'S FEES. <br />