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c o ti� o U S PERMIT#: <br /> Go V il. � v�• STOchib VA <br /> � DDRESS: `Lz�. �• W Is.t3� <br /> jOB S ',�ECLAR <br /> LICENSED CONTRACTOR <br /> with Section 7000 of Division <br /> at ter` 9 (commencing <br /> rovisions of Chap <br /> Code, and my license is in full force°and e{iect. <br /> affirm that I am licensed under the p <br /> hereby 1 71—a Z <br /> 3 of the Business and Processions �>=XpI 10n Date <br /> License# x` 3865 `' tSCt� `' Nvtt�aNM NSI' <br /> Z "Contractor <br /> Date I <br /> 'signature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under.penalty of perjury one of the following deCalarations: <br /> ti I <br /> ", O 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 /> * 0-I'Fiave and will maintain workers' compensation insurance, as reggired 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 /> Carrier J7717'C G1> IS Policy N6mber <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 LaboF Code;I shall forthwith comply with those provisions. <br /> !f Date Applicant <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 /> THE LABOR-CODE,iNTEREST;AND ATTORNEY S_FEES.— <br /> i <br /> f <br /> t <br /> c <br /> .r <br /> i <br />