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JOB ADDRESS: boli 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 fullforce <br /> and <br /> effect. <br /> License# gle?vlo-vS;�- Expiration Date <br /> Date 1' �7 `tD Contractor �G(/IG�1d—� UCoI <br /> Signatur o <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalarations: <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 /> ❑vfSehave 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 /> CarrierPolicy 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 of the Labor Code, I shall forthwith comply with those provisions. <br /> Date 7 U Applicant GiIOIJ G /vrJl.th�(o ( {JCS <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 />