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JOB ADDRESS: 11 49/ 2.4-5 ik)ersr 14,1 e Joey- <br /> <br />PERMIT#: <br /> <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 f rce and effect. <br />Expiration Date // 41, <br />Contractor haffA)W) ‘ie0A-A.,71;hetWAmeArine1 < <br />WORKERS' COMPENSATION DECLARATION <br />License * 6FOZZ .77 <br />Date eVoz/lq <br />e/l) t 6 <br />I hereby ffirm that lh ea certificate of consent to self-insure, or a certificate of Workers' Compensation <br />Insurance, or a certified copy thereof (Sec. 3800, Lab.C). <br />Exp. Date Company <br />O Certified copy is hereby furnished <br />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 ($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 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 />4a, "Ss 1.1-.2.4a4v..-coffl. •