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1r <br /> JOB ADDRESS: o n�R� C ��, C�I v D PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that 1 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 w a Expiration Date <br /> n `/ (0 0 <br /> Date $ !;t-_ Contractor �}C V 79�C eD GC'A �r7V I J4/)rVJ.M-k ) <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers' Compensation <br /> Insurance, or a certified copy thereof(Sec. 3800, Lab.C). --� <br /> Exp. Date /0—O 1 — C,,Q Company ' S I/-� ne,�sG�i p� - roylunc e <br /> 0 Certified copy is hereby furnished '"' <br /> JI(Certified copy is filed with the County Building Inspection Division <br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br /> (This section need not be completed,if the permit is for one hundred dollars(S 100) or less) <br /> I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so <br /> as to become subjectto the Workers'Compensation Laws of California. <br /> Date Applicant <br /> NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers' <br /> Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall <br /> be deemed revoked. I <br />