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J <br />14R00s:cuj1149C 6)Vi9- PERMIT#: 2/ S�3 <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 n Expiration Date <br />Date C)CI_ Contractor � C 1% 7� 1\ ( e (a" 4) C i- 6V I Jo 04,-, J <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation <br />Insurance, or a certified copy thereof (Sec. 3800, Lab..C). I <br />Exp. Date i o — O I — c o Company J) t9 CAmnWSc,- ;w--,-lr1Sv✓L�t e <br />0 Certified copy is hereby furnished �N,✓J <br />X,Certified copy is filed with the County Building Inspection Division <br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br />(This section need not be completed, if the permit is for one hundred dollars (S 100) or less) <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so <br />as to become subject to the Workers' Compensation. Laws of California. <br />Date <br />Applicant <br />NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' <br />Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall <br />be deemed revoked. <br />