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i <br /> JOB ADDRESS: PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am fiCensed under the promnsrortis of Chapter 9(commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code.and my license is m full force and effect. <br /> Ucense w Expiration Date- g L2 On 0 <br /> Date o I t __ Contra= VA tC V" vhf �e C <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm that I have a certificate of consent to seifansure, or a certificate of Workers'Compensation <br /> Insurance.or a certified copy thereof(Sec. 3840, Lab.C). <br /> Exp. Date ''7 r x-06 0 Company tA611C, QY11d1 <br /> ❑ Certified copy is hereby furnished <br /> 0 Certified copy is filed with the County Building inspectjon Division <br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br /> (Ms section need not be completed,d Me pent is for one hundred dollars(S1 00)or less) <br /> I certify that in the performance of the work for which this permit is wed.I shall not employ any person in any mariner sv <br /> as to become sublect to time Workers'CompenSman,taws of California. <br /> Date Applicant <br /> NOTICE TO APPLICANT:lf.atter making th s Certificate of Exeamptron.you should become subject to time Workers' <br /> Compensation provisions of the labor Code,you musifordyMth comply with such provisions or this permit shall <br /> be deemed revoked <br /> i . <br />