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12-01-1999 10:09AM FROM TO 1559268'7125 p.03 <br /> JOB ADDRESS: 3422 W. Hammer Lane, suite x PERMIT#: <br /> f LICENSED CONTRACTORS DECLARATION <br /> 1 <br /> I hereby affirm that I am llcensed 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 r snhj nc) Expiratjon Date <br /> Date 4/12/00 Connctor The Twininq Laboratories, Ihc. <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby aMrm that I have a certificate of consent to self-insure, or a Certificate of Workers' Cornpensaflon <br /> Insurance, or a certified Copy thereof(Sec. 3800, Lab-C). <br /> EXA• Date 10-8-00 Company United Pacific Insurance <br /> O Certified copy is hereby famished <br /> :G Certified copy is flied with the County Building Inspection Division <br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br /> (This section need not be completed,if the permit is for one hundred dollars($100) or tens) <br /> I Certify that in the perfomrance of the work for which this pemtit is issued, I shall not employ any person in any manner so <br /> as to become subject to the Workars'Compensation Laws of Cal'domia. <br /> Date Applicant <br /> N071CS TO APPLICANT: if, after making this Certificate of Exemption,you should become subject to the Workers' <br /> Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit*hall <br /> be deemed revoKea. <br />