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i <br /> j <br /> JOB ADDRESS:,331_ AI ,SIYPC-� 2�� PERMIT#: <br /> %1v_ <br /> j LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division j <br /> 3 of the Business and Professions,Code,.and my.11cense is in full force and.effect x ,rl *• <br /> f .a <br /> ' f License»a '"+ •Expiration Date <br /> t go q, 4 4, o QO <br /> j Date'. , t 5 10 * b 111 nG 1n C <br /> "Cbntracior <br /> ,r i.,` �•,_ of .: .. �# , .. " •;o .',. :: ,, tom. <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 i <br /> //certified copy thereof(Sec. 3800, Lab.C). <br /> Exp. Date 1 OO Company maiden. <br /> T Certified copy is hereby furnished <br /> fWil_1 ,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 (5100)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 any manner so j <br /> as to become subject to the Workers' CompensationLaws of California. ' <br /> Date Applicant <br /> NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' <br /> i Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall j <br /> j be deemed revoked. f <br /> 1 <br /> i <br />