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JOB ADI)RESS __,%V"If ', �*uQ; ' 1 '�� , <br /> PERMITS- <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under this provisions of Chapter 9(commencing with Section 7000 of Divisitlll <br /> 3 of the Business and Professions Code,and my license iso In full force and effect.q <br /> License R 5 L Z(D a Expiration Date q-30 - ZOO I 'r <br /> Dale ntractor 'SPCA,% ., SC/�my C- <br /> Signature <br /> (?KERS' COMPENSATION DI_CLARATION <br /> I hereby at itm under penalti of parjury one of the following decalarations' <br /> O I have and will maintain a certificate of consent to self-Insure for workers'Compensation, a&provided for b, <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. <br /> 1 have and will maintain workers'compansation Insurance, se 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 ate- <br /> Carrier LET ikl"C' - Fpit� PokyNumber <br /> E3 1 cerUly that in the performance of the wink tur which this permit is issued.I shall not employ any person In any manner <br /> so as to become subject to eu workers'CompensN of Calitoomla,and agree that If I should become subject to <br /> the workers'compensation provisions of Section 3 of Oh Labor Cods, I shalt tort 71ticompty with those provisions <br /> Data Applicant <br /> WARNING:FAILURE TO SECURE WORKER$'COMPENSATION COVER HIS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LADOR CODE.INTEREST,AND ATTORNEY'$FEES. <br /> Jim soNs, Spe er EAWOrNon.Inc. <br /> Md1uNn r 3365 W.R.0'.U.m, <br /> ShFNN4.[ID <br /> 3520[1 <br /> 20e.465,11M 10 <br /> 209.665 A)13 1e1 <br /> WA993�IA)7 aN� <br /> 7n9 9 . 2117 nrnln4 <br /> I/ lk <_ £LL859b60Z 1SZ:91 66-9 -9 'N0T1V80­1dX3 Ani:1103dS :A9 1N3S <br />