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r. u <br /> 9-22-1999 A:01PM FROM <br /> 1 , <br /> JOB ADDRESS: 16 l <- ,� 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 -f8s16-r Expiration Date I /S 1/0 <br /> /Z <br /> Date113 of Contractor f2sb <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalarations: <br /> have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> ection 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> Yl.' 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 /> Carrier ALI 0!q Policy Number 88d-- 63Z - 4097 <br /> ❑ I certify that in the performance of the woM 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 Labor Code. I shall forthwith comply with those orovlsions. <br /> Date 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 3706 OF <br /> THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />