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08/03/99 15:50 FAX 902 <br /> I .SjAtIp r' FROtI I P- <br /> I <br /> f,, <br /> JOB ADDRESS: f th ?,(-I 4 �) (A PERMIT#: <br /> 1 <br /> LICENSED CONTRACTORS DECLARATION <br /> f I hereby affirm that I am licensed under the provisions of Chapter 8(commencing with Section 7000 of Division <br /> F 3 of the Business and Professions Code,and my license is In full forces�aa/e <br /> nd effect. <br /> License r Expiration Date —✓Y1' <br /> Date . . 4�5 C CCJ ontractor w 'ft ` <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby arm under penalty of perjury one of the fallowing decelsrations: <br /> ❑1 have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for by <br /> 1JSection 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> �tl 1 have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code. <br /> P for the performance of the work for which this permit is issued. My workers'compensation insurance carrier <br /> and polliipy number are: <br /> iC arrierlf 1l`1� �C1�1�� Policy Number.�5`i ✓. l I —05 <br /> D 1 nertity that in the performance of the work for which this permit is issued,I sha11 note loy any person in any manner <br /> so as to become subject to the workers'Compensation lapis of California,and agree that if I should become subject to <br /> the workers'eompensafion provisions of Section 3700 the Labor Code,1 Shap f th comply with those provisions. <br /> Date v;-. 'a C�� Applicant <br /> i <br /> I 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 /> i (1 D0.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> I THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. <br /> i <br /> i <br /> i <br />