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s a <br /> .SOB ADDRESS: " �- PERMIT#: <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 Cade, and my license is in full force and effect: <br /> License#� aA _ Expiration Date �L4J�-t-A—/ _ <br /> Date _. Contractor ,1 n]k/]G._ 2T-x- , - -- <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> hereby affirm under penalty of perjury one of the following decalarations: <br /> 0 1 have and will maintain a certificate of consent to�self-insure for workers' compensation, as provided for by <br /> Section 3700 of the tabor Code, for the performance of the work for which this permit is issued. <br /> (I have and will maintain workers' compensation insurance, as.required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance carrier <br /> and policy number are: <br /> Carrierlwn 6ale, Policy NumberQ,ll�� <br /> © 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner <br /> so as to become subject to the workers' compensation'laws of California, and agree that if I should become subject to <br /> the workers'compensation..provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. <br /> Date Applicant I. <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <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 /> I ELABORCODE, INTEREST,.ANDATTORNEY': F_ ES. <br /> i <br />