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10/18/1599 16:40 2094671118 <br />AGE STOCTON <br />PAGE 02/02 <br />r7 <br />,cam <br />JOB ADDRESS: 7Q 6 �� E D��'O PERMIT#: — ) <br />LICENSED CONTRACTORS DECLARATION <br />I nereoy a!flrm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br />3 of the Bus"$$ and professions Code, and my Iicense 13 in 9 fou erect. <br />License R �L Expiration Data <br />Date � Contractor <br />WORKERS' COMPENS ON DECLARATION <br />I hereby affirm that 1 have a ce,"cate of =.sent to so -insure, or a certificate of wO"ker's, Compensation <br />losurancO, or a earned Copy thereof ;Sec. 3800, Lab.C)• <br />F.rp, Date —N -) 0 U�— <br />Company <br />C2 Certified ropy is nere6y furnished <br />oCen,hetj copy is filed with the Covnty 301ding Inspection Division <br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br />(Ns yclion need not b4 completed. H trig WMA is for one hundred dollars (5100) or to") <br />efson *1 any .Wanner so <br />U'at in the perlortr ir>Ce <br />I ceNy of tree work for whdi thts permit is issued t st�l not "joy, nY P <br />as �o Jerome suspect to the 1Norkeri' Compensation hews 4f Gafftrni3. <br />pate Applicant <br />NOT)C!s TO sFPLICANT N, ■Flsr making this Certificate of lexe 0m you should become sub}act to t1ie 1Norkors' <br />Cornpensition provitibns of the Labor Code, you rnustforthwith comply wig such provisions orthis permit mall <br />1 De oeemru off— ^ <br />., ... . 4: .l^ 1..- .. <br />ze 39ad <br />? eeeeeeeaeee LS:bT 6661/8T/BT <br />