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JOB ADDRESS: 6, S5 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# 7 e? Expiration Date z�✓�/f Dl <br /> Today's Date �� ! f Contractor 4Z I, (��,P,Pq,a) rk,lr>A'rft�//y <br /> Signature <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 i '�`�''� ' Company <br /> ❑ Certified copy is hereby furnished Aelx_.+ -t1-o51"94' 0000 337 <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 />