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7-20-1999 1 :39Pr1 FROM " <br /> JOB ADDRESS: 70 IN l tdiyf-K R� , L041 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 Code, and my license is in full force and effect. <br /> License Expiration Date 104 ivay <br /> .w <br /> Date �nZ (/4g Contractor ATC &AQW0 154'IViLZ S <br /> Signature `lt/k'C , ��• ["M ° — <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 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: p <br /> CarrierAl•1� ILAW INnE �S� MTN GQ Policy Number S�0 �O Z r� G/i/94 6J rauo <br /> 1 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 subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. /]�n <br /> Date <br /> 7 ) Signature: / UI/ e <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 /> ADDITION <br /> TO THE COST OF <br /> INTEREST,AND ATTORNEY'S FEES.COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LABORCODE, <br />