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I <br /> JOB ADDRESS: 1105 laVQ#a�VAMe f4MJ 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 <br /> and effect. <br /> License#61 Expiration Date <br /> Date Contractor JkW2! O! G, L_ I IIJCi <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalarations: <br /> ❑ I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> /S ction 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> 1have 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 LikQ tvt,7 MJ _Y W,, Policy Number <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, off the Labor Code, I shall forthwith comply with those provisions. <br /> Date 0Applicant �IiCil�tD� �� tif ISL' <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 /> (900,000), 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 />