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7-01-1999 3: 12PM FROM P. 2 <br /> • <br /> JOB ADDRESS: ) 1U - ,, 7_r-? CQ PERMIT#: Q �� <br /> LICENSED CONTRACTORS DECLARATION <br /> I I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br /> 3 of the Bushiness and Professions Code, and my license is in f/111fo and effect <br /> License# 4bSl (p S Expiration Date 0 ✓� <br /> r= <br /> Date D C'�r Contractor req ��I f r✓l�! <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the`following declarations: <br /> I 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 /> i <br /> i I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work fcr which this permit is issued. My workers'compensation insurance carrier <br /> and policy number are: <br /> Carrier <br /> �� ��'1� Policy Number_ LyG10 //D A/f,341 <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 SLbject to the workers' compensation laws of California, and agree that if I <br /> should become sub;ect to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> ' <br /> Date Signature: <br /> L <br /> NING: FAILURE TO SECURE WORKERS'COMPENSA710N VERAGE IS UNLAWFUL,AND SHALL SUBJECT. <br />_�---._ MPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> 00), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OFABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />