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9-20-19yy 1 l7:b 1 AM f•KUM E� <br /> w <br /> JOB ADDRESS: 15YI /I1aln S ,. j�' PERMIT#: I <br /> I <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that l 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 <br /> I <br /> Expiration Date ' <br /> f �i�r�c,` �\�uv�w.e�fa _,, <br /> Date Contractor o.v�n <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm that l 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). <br /> I <br /> Exp. Date I 2p0 Company R -EeV"V\ <br /> tV <br /> ❑ Certified copy is hereby furnished <br /> E3 Certified copy is filed with the County Building Inspection Division <br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br /> i <br /> (This section need not be completed;if the permit is for one hundred dollars(S1 00)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'Compensatior.Laws of Califomia. <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 pennit shall <br /> be deemed revoked. <br /> o i <br /> - � y <br />