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JOB ADDRESS: `�` 2117CO4 � PERMIT#: <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 Busines(,ss and Professions Code, and my license is in full force <br /> �at <br /> and effect. <br /> License w U bQ / <br /> � 7 Expiration Date 30 WOO / / <br /> Date 2 bov 93 Contractor �/d�tfld 6eo,�=`z�Yo�� - <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers'Compensation <br /> Insurance, or a certified copy thereof(Sec. 3800, Lab.C). 131 7 q7,q -9'8 <br /> Exp. Date Company �`" <br /> ❑ Certified copy is hereby furnished <br /> ❑ Certified copy is filed with the County Building Inspection Division <br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br /> (This section need not be completed,if the permit is for one hundred dollars(S100) or less) <br /> I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so <br /> as to become subject to the Workers' Compensation Laws of Calffomia. <br /> Date Applicant <br /> NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers' <br /> Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall <br /> be deemed revoked <br /> • - a. -�..-.- z .... .aar.vwx:.,.-xw-sreik:.�r't..rsiLPft��+ena.:�:_.-�.s�.....v�.:s+►.-:•--•.rx..m-:: .�-c>.,..: .+R. <br />