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Nw .. <br /> JOBADDRESS: 1610 E, 1l41el }oK Ave.l , Sfocktph 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# 6 716 11 Expiration Date 6 13010-; <br /> Date 10 131101 Cofitractgr hj 1tt11 OV011N Etivfro4k, e4}gl, <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalaralions: <br /> ❑ 1 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 v (/ k--('l/w Policy Number IS S6641- 00 <br /> ❑ 1 certify that in the performance 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 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 />