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08/23/99 MON 18:50 FAX 510 663 6350 GROMATRI% OAKLAND IgD03 <br /> • a <br /> JOB ADDRESS:�OQ� 5c�1 lir KD• . P1rIxMl #: <br /> LICENSED CONTRACTORS DECLARATION <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br /> 3 of the Business andProfessionsCade,and my license is in full force and effect <br /> Expiration Date ( I ;LEZ <br /> License <br /> / <br /> ❑ate 7rm <br /> ContractorSignaWORK ' COMPENSATION DECLARATION <br /> 1 hereer penalty of perjury one of the foilawing declarations: <br /> saflon, as <br /> I <br /> have n3700 of the Labor certificate <br /> for the performance of the work for which thisenpermit is issurded for by <br /> ed <br /> Section Cor <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%IP Z!rla? _ Policy Number <br /> I certify that in the performance of the work for which this permit is issued,)shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if I <br /> should become subject to the workers'compensation p vislons of Sec/'on 00 of the Labor Code, I shalt <br /> forthwith comply with those provisions. <br /> Date q Signature: ` <br /> WARNING: FAILURE TO SECURE WORKERS'COMPE TION COVERAGE IS U WFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL NES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,000),IN ADORION TO THE COST OF COMPE ON,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE.INTEREST,AND ATTORNEY'S F£E3. <br />