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08/23/99 RON 16:52 FAX 510 663 6350 GEOIIATR IX OAKLAND [A 005 <br /> . r <br /> JOB ADDRESSc 17 D6 l5 M Ag� PERMI r# <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 9usiness and Professions Code, and my license is in full force and effect. <br /> License# Ex ra:ionDate <br /> W���� / - p° T� <br /> g <br /> Date actor <br /> Signature <br /> WORKER ' OMPENSATION 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 Cade,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 Cade, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance carrier <br /> and policy number are: n n <br /> �Ur.I D Policy Number <br /> Carder <br /> I certify that in the performance of the work for which this permit <br /> is issued,f shall <br /> Caliln ae mploand agree th iy any s f f in <br /> any manner so as to become subject to the workers' camps <br /> should become subject to the workers'compensation p ons of Sectio 37 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date�V� Stgnature: _ r <br /> WARNING: FAILURE 70 SECURE WORKERS'COMPEN TION COVERAGE 6`i UNLA UL,AND SHALL SUBJECT <br /> {AN EMPLOYER To 100,000).N ADI)MONIMINAL PENALTIES AND TO THE COSTO COMPEN L FION,DAMAGUSAND DOLLARS <br /> ES AS PRO OED FOR N SECTION 3706 OF <br /> THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES. _!_ --- <br />