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�} 8-06-1999 12-50PM FROM P_ 3 <br /> y <br /> _M <br /> J013 ADDRESS: L � �7 r�ERMIT#: <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 andel effect. <br /> License# (&& 2,;?7) Expiration Date—/O- "-q 1 <br /> Date Contractor MQ <br /> Signature <br /> rJ <br /> VORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: <br /> 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 /> I 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 /> 77[+15gXIe q <br /> Carriers%R7'�,G�1� ,F-yn 0 _ Policy Number 1,S1/ � y� t <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, 1 shall <br /> forthwith comply with those provisions. <br /> Date 'Cb 1qjSignature: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION CO RAIS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CIVIL FINES UP TO ONE NDRED 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 />