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JOB ADDRESS: �. 6 `; �iLQc-c.�, PERMIT#:SR# <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 Professions Code, and my license is in full force and effect. <br /> License# � �• Expiration Date 2• I • 00 <br /> Today's Date • (• (� Contractor VW%PneAO .1 G.�OQA�I.��i Irl ll�• <br /> Signature��4 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers' Compensation <br /> Insurance, or a certified copy thereof(Sec. 3800, Lab.C). <br /> Exp. Date 2 • I • 0 Company Aw X�; Not? <br /> ❑ Certified copy is hereby furnished <br /> ❑ Certified copy is filed with the County Building Inspection Division <br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br /> (This section need not be completed, if the permit is for one hundred dollars ($100) or less) <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so <br /> as to become subject to the Workers' Compensation Laws of California. <br /> Date Applicant <br /> NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers' <br /> Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall <br /> be deemed revoked. <br />