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{09/]5/99 IYF:D 13:38 FAX 510' 663 6350 cFoi;wrRIX OAKLAND 0;003 <br /> `�`{i fes" • j � y 4 <br /> JOB-ADDRESS: I l r2� w. '� 1 ILA" <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby afi<nn that l am ricensed under the provisions of Chapter 9{commencing with Section 7000 of Division <br /> 3 of the Business and Professions Cade,and my license Is in full force and effect. <br /> License# CQ(���j�f Expiration Date <br /> Date Con actor 12�&JZ—AC)P-1 Gj�P;� <br /> Signature <br /> WORKERS' MPENSATION DECLARATION <br /> I hereby a under penalty of perjury one of the following declarations: <br /> I have and will maintain a certiffcate Of consent to self-insure far workers'campensatian, as provided for by <br /> Section 3700 of the Labor Code,for the perfornmee 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 Policy Number <br /> I certify that in the perfom-ance 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 rovislcns of Section 3700 of the Labor Code,l shall <br /> forthwith comply with those provisions.- <br /> pate Signature: <br /> WARNING:FAILURE TO SECURE WORKERS,GOMP ATION COVERAGE tS UN UL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CIVIL IiNES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,000);IN ADDITION TO THE COST OF COMPEN TION.DAMAGES AS PROVIDED FOR iN SECTION 3706 OF <br /> THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. <br />