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JOB ADDRESS : "✓1 7 5cc v '7%14 1" DpAoPt�? PERMIT#;`: <br /> + <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 �' �� 49 Expiration Date} i , u ^ ZpoP <br /> Date �� Contractor 1 � VQV) � � Vivi ^0011 'IMI'+j,�O tT'1k0 <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 n( c l , 'ZD Company L i TL Cr.eWflx Tjoil , �✓f5vr � � <br /> 0 Certified copy is hereby furnished <br /> 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 ($ 100) or less) <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in a6y manner so <br /> as to become subject to the Workers' Compensation Laws of California. / <br /> Date Applicant <br /> i <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. <br />