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a <br /> JOB ADDRESS: Ska6() &/PERMIT#: <br /> LICENSED CONTRACTOR DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 8 (Commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code, and my license is in fill force and effect <br /> License (060 2a--] Expiration Date <br /> :-AsA <br /> Date r 7 A.)6VS-T ) a0 Contractor 'NO G_p Mi ►J6F 7 L t s <br /> Signature <br /> W KERS' COMPENSATIO DECLAMATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: <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, a required by Section 3700 of the Labor Code, <br /> for the performance of the work for which.this permit is issu d. My workers'compensation insurance carrier <br /> and policy number are: p• <br /> �'1 H'I"F.- Cp,�pl:n5c,+f n n �i1Sv rca►�[C. �C�� �'� �����U _ <br /> Carrier Policy Number <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'comps nsabon 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.) 7 P/ yi. ! f ( 1 Signature: ��k, 4, <br /> WARNING. FAILURE TO SECURE WORKERS'COMPENSATION COVE GEIS 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, DAN AGES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. <br />