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cltY .. sioFWALK IN FRONT oT <br /> JOB ADDRESS : 130 N . NUNTLR' 5TKErT 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 2 6 l } Expiration Date 6 ( 3 0 10 3 <br /> Date 5129101, Co r for MI tHFLL DRI LLIN � ENVIRONMENTAL <br /> Signature <br /> WORKERS ' COM ENSATION DECLARATION <br /> f 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 /> Ci(I 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 STAIF COMPFN5A'TiON FUND Policy Number IGWot4j — OO <br /> ❑ I 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 /> (1003000), 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 /> II <br /> u <br />