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I <br /> ications Station , San Diego Detachment <br /> Naval Computer & Telecommun <br /> I <br /> J08 ADDRESS : dins 2 41. 0A & 508 PER ' ' ° ---- � <br /> j Stockton , CA <br /> ' I <br /> LICENSED CONTRACTORS DECL�1 �`:`' . <br /> I hereov arl; rm that I am licensed under the provisions or Chapter 9 ( comment.(i Sect &.. 7000 of Division <br /> 3 of the Business and Professions Code , and my license is in full force and eff ^ - <br /> � � - s896O il � 19 � <br /> i License � expiration Oata ; <br /> I <br /> Cate <br /> WORKERS ' COMPENSATION DECLARAri '- i <br /> A i <br /> hereby aifrm that I have a certificate of consent to self-insure, cr ace,,] ficat : ci <br /> , rice , ' , ; -^ p � nsation <br /> insurance , or a certified copy thereof ( Sec. 3800 , Lab. C ) _ <br /> oxo . Cates © � a 1 /CX3 ComoanvC � '% ^ �I <br /> i <br /> j Ceriaed copy is hereby furnished i <br /> O Certi 'ied cony is filed with the County 3uildinq Inspection Division I <br /> CERTIFICATE OFEX= MPTION i-ROM WORKERS ' COVIPENS '-. � ' iNSv ANCE <br /> r;hts section need not be completed , if the permit is for one hundred collars ( 5100) or ! oss : I <br /> cel ` / that ; n the performance of the work for which ;his permit is issued , I shall not ec.c : _ -y . erso : ; a -y manner so <br /> as to oecome SUDiect to the Worxers ' Compensation Laws of California . <br /> Date Applicant — <br /> ,,; GTiC � 70 ,kPPLICANT , if, after making this Certificate of Exemption , you should = = erne suajcc: to the Workers ' <br /> ce) mpensation provisions of the labor Code , you must forto'lwith comply with suc '� c -� v :sion4 ;, r ., is permit shall <br /> be deemed revoked . <br />