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JOB ADDRESS: PERMIT#: <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 C gl'IbJnsExpiration Date D/j341O Z <br /> r <br /> Date Z l L6 1,7f Contractor r /rill A� T2�/�-e <br /> Signature a•✓ pCiel, <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury One of the fallowing decalarations: <br /> KI have and will maintain a certificate of consent to self-insure for workers' compensation. as provided for by <br /> E Section 3700 Of the labor Code, for the performance of the work for which this permit is issued. <br /> exIhave and will maintain workers'corripensation insurance. as required by Section 3700 of the Labor Code, <br /> nor the performance of the work for which this permit is issued. My workers' compensation insurance carrier <br /> and policy number are: <br /> Carrier A Trn479- Policy Number 940� • Z' <br /> 0 1 certih/that in the perfortftance 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 Laoor C ae. I shall forthwith comply with those provisions. <br /> Date 2 Applicant L' relmngd <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 3706 OF <br /> THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />