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JOB AD15RESS: <br />PERMIT# <br />LICENSED CONTRACTORS DECLARATION <br />... .............. <br />I hereby affirm that I am licensed under -he provisions Of Chapter 9 (commencing with Section 7000 of Divigi0f, <br />3 of the StisineSs and Professions Code, and my license is in full force and effect. <br />License 9 12— 2. (0 <br />IFYnkation naip �30 — 2-00 1 <br />ul,ia ntraclor 0 C <br />Slonsturo KERS, COMPENSATION bECLARATION <br />I hereby offurn under penalty Of perjury 0110 of the following decalarations- <br />I] I have and will maintain a certificate of consent to self -insure for workers' Compensation, as Provided for b,,, <br />Section 3700 Of the Labor Code, for the performance or (he work for which (11118 petmil is Issued. <br />131 hays and will maintain workers' compensation Insurance, as required by Section 3700 of the <br />for ft performance of the work for which this permit Is Issued. My workers' Labor code, <br />and Policy number are: compensation insurance carrier <br />Carrier_ Ti—S� Policy Number 51 LJIL!5n�S71 <br />I , rfify that :�-Iormsnce of the work for which this permit is issued. I shall not employ any person In any niatirier <br />o" <br />sQts o is to bec( k) the workers' n Col'"s, and ogres that if I should become subject to <br />wofltars'r 01(yvisioris of orn and <br />fort <br />"h c <br />CSecf1k)n 3 of "i Labor Code, I shall fort*lh comply with those provisions <br />Applicant <br />WARN1140 .!RE TO SECURE 7- -- <br />AN EMPJ,O; WOR" -AS' EIS 4. <br />VIER UNLAWFUL, AND SHALL SU13JECT <br />W CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSANO DOLLARS <br />LT(i00,000j. IN i DITION TO THE COST OF COMPENSATION, DAMAGES As PROWVED FOR IN SECTION 3706 OF <br />—R;71i,R Cc. "0, INTEREST. AND ATTORNEY'S FEES. <br />MOM IiII11111111h, ar dam MMM am AW W M <br />U -M <br />Jim kloinfolew Soecfwm E. DIO�rllun, Inc. <br />209.46 S. A 712 <br />20 1 46" A I I j <br />la <= CLZ999V60Z !W:91. 66.9 -9 !N0I1VH01dX3 Nnu133ds :AS IN3S <br />