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i Apt-27-00 01 : 28 P - 02 A JOB ADDRESS- 'P!E`RMl''fiAr LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under,the provisions of Chapter 9 (commencing with Section 7004 of Division 3 of the 113usiness and Professions Cade, and my license is in full force and effect. License# C�? -.55� ! q� Expiration Date � c3 o(/ Date Li ' a 7 contractor WQ.5i0.2r1 g7lzim) _Lxptc-kZF�-TM Drn, Xb . WORKE ' COMP_ ENSATION DECLARATION I herebyVfirm under penaltVoff-perjury one of the following declarations: I have and will maintain a cert9fcate of consent to self-insure for workers'eornpetasation, as provided for by Section 3700 of the Labor Code'Kor the performance of the work for which this permit is Issued- I have 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- Carrier. re-Carrier STIA Te Policy Number /5C-�478�1-Oy I certify that in the performance of the work for which this permit is issued, I shall riot employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if l should become subject to the workers' compensatlon provisions of Section 370 f the Labor Code, I shalt forthwith c mply with those provisions. Date y 7 Signature- WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLIWFUL.AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND COLLARS (1130,00d), IN ADDIVON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LASOR CODE, INTEREST,AND ATTORNEY'S FEES, �I