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Ga'vNtY , pA:t hcNG GARN & E JOB ADDRESS : 13 O N i4 V Nk t [ R 5r R E T PERMIT# : f LICENSED CONTRACTORS DECLARATION I he affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division 3 of the Business and Professions Code , and my license is in full force and effect. License # 6 3 `� 5 Expiration Date Date /!Z�'%:?�U Contractor 1- i 5 CN /� Signature fLW WORKERS ' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following decalaralions: ❑ I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued . &4flave and will maintain workers' compensation insurance , as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued . My workers' compensation insurance carrier and policy number are: / Lin Policy Number /536aa5 oo Carrier ❑ 1 certify that in the performance of the work for which this permit is issued , I shall not employ any person in any manner ' so as to become subject to the workerscompensation laws of California , and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date //�Z/ - /zL) Applicant 7. / 656*4 AWARNING : FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL N EMPLOYER O CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARSUBJECT Ili 00 ,000), IN ADDITION TO THE COST OF COMPENSATION , DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES .