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Apr`-27`00 01 : 28 s-- P -02 <br /> r• <br /> JOB ADDRtSS: -PERM]-T-#r ' <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 ©ate <br /> Date Ll • a 7- 00 ContractorW�S t�.2 y1 3?�z L x 1,�t2r Dv -ry e . <br /> Signature - <br /> WORKS ' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: <br /> I have and will maintain a certificate of consent to self insure for workers'compensation, as provided for by <br /> Section 3700 of the tabor Code,for the performance of the work for which this permit Is Issued. <br /> I have and wilt maintain workers'cam pensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of tha work for which this permit is issued. My workErs' compensati❑n insurance carrier <br /> and policy number are- <br /> carrier.911"IfF utUta Policy Number ><5L�9rl84—Oc� j <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in i <br /> any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 37 f the Labor Code, I shall <br /> forthwith c mply with those provisions. [1 <br /> Date y 1 Signature" <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWPUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND t3OLLARS <br /> (100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIOEb FOR IN SECTION 3708 OF <br /> THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. <br /> . j <br /> I <br /> . f <br /> F <br />