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JOB ADDRESS: 7-777 6-311 YL S% /-RACY C4- q5_5 2� PERMIT#: <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 # ►1 l y Expiration Date L ' C <br />1 <br />Date Contractor (-L, <br />Signature <br />/ WORKERS' CON"PENSATION DECLARATION <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 which 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 />and policy number are.- <br />Carrier <br />re:Carrier 5 T17r- ",Cw) Policy Number SL,,; OC' ,- -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 />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 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date <br />Signature: <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 />