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, <br />JOB ADDRESS: 77- <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 force and effect. <br />License 4' (;, S7 0 12 7 Expiration Date <br />Date 74, 7? Contractor 1-'4-1/Laa -0fQ <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). <br />Exp. Date 1°—°1—c:R.Pt-'(--) Company _ <br />Certified copy is hereby furnished <br />0 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.