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JOB ADDRESS: 11311 N • HWY 99 AGA MI'0 PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> 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 /> Ucense# C- 4.4 20 9 01 Expiration Date 4 30 0-L <br /> i <br /> tDate — O� Contractor V W R 1 L�t N 6�l N G . <br /> ,Signature LIWIP6 il� <br /> WORKERS' COMPENSATION DECLARATION <br /> ereby affirm under penalty of perjury one of the following decalarations: <br /> ave and will maintain a certificate of consent to self-insure for workers'compensation, as provided for by <br /> Sction 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> I haverid VM 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 71IM334 7 I <br /> ❑ 1 certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner <br /> so as to become subject to the workers'compensation laws of California,and agree thiplf I should become subject to <br /> the work s'compensation provisions of Section 3700 of bor Code,l s II fo comply with those provisions. <br /> Date LO� Applicant , <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL'FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR 1N SECTION 3706 OF <br /> THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. <br />