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F <br /> JOB ADDRESS: 14)"t-1 SDI PERMIT#. <br /> LICENSED CONTRACTORS DECLARATION <br /> f <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 1 Gam? 5�6 Expiration Date <br /> f i 1 <br /> Date !2 Z °r' Contractor <br /> Signature f <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalarad6ns: <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 /> ,)<ihave and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Cade, <br />' for the performance of the work for whicn tris permit is issued. My workers' compensation insurance carrier <br /> and policy number are: <br /> Carner GQl Policy Number <br /> ❑ I certiPj that in the performance of the worx for which this permit is issued,'+l shalt not employ any person in any manner <br /> so as to become subject to the workers' c:rnpensarion Laws of Califomia. and agree that if I should necome subject to <br /> the workers' compensation provisions of Section 3700 of the-'-abor Co � . I shat) forthwith comply with those provisions. <br /> i <br />{ Date /_? /7, Applicant <br /> 4 WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS iUNLAWFUL,AND SHALL SUSJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,000), IN AODITION TO THE COST OF COMPENSATION, DAMAGES AS PRdVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE, INTEREST, AND ATTORNEY'S FSES. <br /> i3 <br /> i <br /> i <br />{ <br /> i <br /> i <br /> i <br /> t <br /> 1 <br /> Ij <br />