Laserfiche WebLink
b-11-1999 11 :47AM FROM P. 5 <br /> �rc:cr - L.PJktn9.. �Qo7" .Tw JO4�,l�`1 <br /> JOB ADDRESS: PERMIT#: <br /> ':>`S5-7 <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#0S7 VkS/6 r Expiration Date <br /> r / / ---00QDate Contractor Ve�Z4 2a2,1 <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalarations: <br /> 0 1 have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued, <br /> n' 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 G 7 Policy Number 9 �3 <br /> D 1 cenify 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 that if I should become subject to <br /> the workers' compensation provisions of Section 3700 of the Labor Co0e.Is orthwith comply with those provisions. <br /> Date C l/ ��% Applicant & -- <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,000), IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. <br />