Laserfiche WebLink
I _ 1 <br /> k , <br /> M <br /> JOB ADDRESS:_ S OD WO-S �.�,� S� PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> ,k I <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 Iii full 7foceand effect. <br /> License Expiration Date I O I <br /> Date ntractorC. <br /> Signature <br /> 4 WORKERS' COMPENSATION DECLARATION <br /> F <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 Whitt, 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 /> iand policy number are: <br /> F <br /> Carrier ru od' <br /> Policy Number <br /> i � <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> ) <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 the Labor Cade, I shall <br /> forthwit) com iy with those provisions. a,'Date t Signature: <br /> F <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'COOE;'INTEREST;AND'ATTORNEY'S FEES. <br /> s <br /> S' <br /> _ I I <br /> f <br /> I <br /> I I <br /> I <br /> 4 <br /> i <br />