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9_22_1999 4:01PM FROM r <br /> D A) � �( <br /> JOB ADDRESS: ,l Q� <br /> 2lf 9� �, eLP�u.QY PERMIT#, 962,6 OU=P <br /> ^-- <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter g (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 -��� Expiration Date C?I- L=/ O <br /> Date <br /> 3 O Contractor j �/'el`/ito <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 /> Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. <br /> 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 /VX J0& Policy Number�t�, �S 3Z— �1D 9 7 <br /> ❑ I certify that in the perfonrtance of the wont 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 1 should become subject to <br /> the workers' compensation provisions of Section 3700 of the Labor Code. I shall forthwith comply with those provisions. <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 />