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l <br /> i <br /> i <br /> i <br /> J09 ADDRESS: q,)7 5 m `u'" PERMIT#: <br /> I. <br /> I. <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of chapw 9(commencing witty Section 7000 of Division <br /> 3 of the Business and Professions Cade, and my license is in futi forte and effect <br /> License* Expiration Date <br /> Date go e* <br /> Signature <br /> WORKERS' COMPENSATION QECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalarations' <br /> ❑ I have and will maintain.a certificate of consent to self-insure ferworkers'compensation,as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is+ssued. <br /> ❑ I have and will maintain workers'compensation insurance, as required by Section 3700 of the labor Code. <br /> for the performance at the work for which this permit is issued. My workers' compensation insurance carrier <br /> and policy number are: <br /> Carrier Policy Number <br /> PJ I certify that in the performance of the work for which this permit is issued. i snarl not employ any person in any manner <br /> so as to become subject to the workers'compenwoon laws of California,and agree that if I should become subiect to <br /> the rkers'oomoonaation provisions of Section 3700 of Labor Code.I s If forthwith comply with those proviviOna. <br /> Date Applicant ,�f � <br /> WARNI : FAILURE TO SECURE'WORKERS'COMPEN TIOrM C ERAGE IS UNLAWFUL—AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL.FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (140,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECnON 3706 OF <br /> THE LABOR CODIL INTEREST,AND ATTORNEY'S FEES. <br /> E0 39Vd ? 00000000000 69:ET 6661/91/L0 <br />