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uol"199 14:40 FAX <br /> Z03 <br /> JOB ADDRESS: PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION ' <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9 {commencing with Section 7000 of Division <br /> 3 of the Business and Proiessions Code, and my license is in full force and effect. <br /> License# 720904 Expiration Date <br /> Date June 10, 1999 Jody A. Vickery <br /> Contractor y <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalarations: <br /> © 1 have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for by I <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> f l 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: I <br /> Carrier C201depq Policy Number <br /> 171 1 certify that in the performance of the work for which this permit is issued, 1 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 Code, I shall fgAhwith comply with those provisions, <br /> Date June 10 . 1999 <br /> 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 IN SECTION 37()6 OF <br /> THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES_ <br />