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' JOB ADDRESS:S//d Avc 5ZXr-TOS 44 PERMIT#: <br /> LICENSED CONTRACTORS 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 full force and effect <br /> License# 137 4 2Z Expiration Date fso�.1i= <br /> Date /o a Contractor T cc>'r-C't>ar C Y.A <br /> Signature IT 2,aT1 DyJ <br /> WOR S' COMPENSATION DECLARATION <br /> ' i hereby affirm under penalty of perjury one of the following declarations <br /> 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 Issuers <br /> have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued 11,workers' compensation insurance carrier <br /> and policy number are <br /> Carrier 1c Mc,L.B"N-AoA of Vklm Poll Number 17$ pp — `'Z °I-- U 3 i I"1 L-P(L_ <br /> ;� �t,a rc_s�,L_ Policy <br /> ' I 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' compensation laws of California and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> ' forthwith comply with those provisions - <br /> Date �y�y` !J`� Signature: <br /> :-!-a <br /> + o� <br /> ' WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 1 NLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINIS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. <br /> 1 <br />