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/Zlow ? <br /> IL <br /> JOB ADDRESS: I 'A Q� �,���{��p 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 Expiration Date C 1 -,zn I zbca <br /> Date Contractor r-.� <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm ander penalty of perjury one of the following declarations: <br /> I have and wilt 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 /> 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 /> I <br /> Carrier Policy Number <br /> I certify that in the performance of the work for which this permit i ued, I all not employ any person in <br /> any manner so as to become subject to the workers' c ion fa C lifornia, and agree that if I <br /> should become subject to the workers' compensat provi ' ns of i 3 00 of the Labor Code, I shall <br /> forthwitcomply with those provisions. <br /> Date Signature <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENS ION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN FMPLOYFR TO CRIMINAL PENALTIES AND CIVIL FI S UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (700.0001_IN ADDITION TO THE COST OF COMPENSAT ON. DAnnACES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE, INTEREST,AND ATTORNEY'S FE S <br /> (74 <br /> r SEP 13 2001 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> I d Nodzl WVVV:8 6661-9Z—L <br />