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b—OA-.1999 3:45PM 11.R D <br /> JOB ADDRESS; aak4rkKo s rPERMIT# Oonp <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br /> 3 of the Business and Professsiionn&Code,and my license is in full force and effeot. <br /> License# P;! !JZ9i5 1 Expiration Date®(1 3/11/x( _ <br /> Date _ Contractor f��/ft�� ®//!!A� 116 rkin& . <br /> Signature- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalaraboos: <br /> 1 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 /> have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> or the performance of the work for which this permit is Issued. My workers' compensation insurance carrier <br /> and policy number are:umG <br /> Carrier G -064 . -T policy Number Ts _0000 vCj� <br /> certify that in the performance of the work for which Ws parmit is Issued,I shall not employ any person In any manner <br /> so as to became suoiect to the workers'compensation laws of California.and agree that if I should become subject to <br /> the workers'cornpensation provisions of Section 3700 of t t8 ,I shall forthwith comply with those provisions. <br /> Date--A"" Applicant - P, tL— <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT I <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, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES, <br /> Post-IC Fax Note 7871 oats u D ' ` <br /> Tp FrO1p <br /> Cp./UeDI. A .1 co, <br /> ve abed `•SV:Z o0- LC-bnV !eOCO ELC 9Z6 ` 'ouI '6ui}S8l g buTTTTJC 660JO :AS 1u08 <br />