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9-22-1999 d:I71PM rmum <br /> JOB ADDRESS: o 6owe. r�.•.a.. -o &wPERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 4 (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 Expiration Date ] d <br /> Date Conuactor, 2 ! £s1E'"--= <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalarations: <br /> k have and will maintain a certificate of consent to sett-insure far 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 /> l.. <br /> have and will maintain workers'compensation insurance.-as required by Section 3700 of the labor Code. <br /> j <br /> for the performance of the work for which this permit is issued. 'My workers' compensation insurance carrier <br /> and policy number are: <br /> Carrier 6;�;EY _ Policy Number <br /> Cl I certif</ that in the performance of the worK for which this permit is issued. I shall not employ any person in any manner <br /> so as to become subject to the workers compensation laws of Califomia.and agree that if I should become sumiect to <br /> the workers' compensation-provisions of Section 3700 of the._.sbor Code. I all forthwith aosnPiy with those provisions. <br /> rC ? Applicant <br /> I{ <br /> Date l _— pp <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (144,000},.1N AO DI. 14N TO.T.N>^.COST QF COI►APENSAFION,=DAMiIGES ASPR_OVIDED FOR,IN SECTION 3706 OF_ <br /> THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. Ir <br /> i <br /> i . <br /> t <br /> 4 <br /> i <br />