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_-�.,.—•-tom;;---` <br /> FROM West l-iazmat FAX NO. 19166368613 r. Dec. 27 1999 01:16PM P1 <br /> JOB ADDRESS: PERMrr#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that t am k *n$ed under the provisim of Chapter 9(oarnrnendng wf h Secdon 7000 of Division <br /> 3 of the Susihass and Pmfmk)-nt Cocte, and rry 56-anse is in full force and ef`ieot, <br /> License Y`72 <br /> " F-xpIraWn Date , 4�6 <br /> Date .�',�/ �`� Cantra=r, : r <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm that I rya a certificate of fit to w f-•insure Ora certlf�te of Workers' Compensation <br /> tntsurance, W a cer�tff=e i ae 3800. t..ab.C)." <br /> Exp. Date 0 Lf 11011A600 r Company <br /> a COrtifieo aapy is hereby fumi-,hecf <br /> C3 Csrtitfad copy is tied with the County Building Inspection Division <br /> CERTIFICATE OF EXEMPTION FFtOM WORKERS'COMPENSATION INSURANCE <br /> (Thi;auction need nit be cornplet*d,if ft permit is for we hunared dodam(Siou)Qr 10531 <br /> I cortify that in the performarnow of the work for which the pam-dt is issubd,l shall not employ a' person in any manner as <br /> as to become 4ubJxct to the Workers'Compensa0on Laws of Callfomia. <br /> Date / APPfiicant <br /> NOTICE TO APPt_1CANT:If,after making Chia Ca 'i3cata of pxempticm,you ahouid bocorne s jcct the Workers' <br /> Compensation proyisiorts of the Labor Code,you must forthwith tomply with such provision* r this rmit 6hrcll <br /> the deemed mYvkacL <br /> - w. .,.,wee. :r•�-.r. .. .,� ` Y �� ' f _ <br /> i91Ta 39Vd NOl?iOCJ�S 39V BTTTL9G69Z 1:0:El 6661/LZ/Zl <br />