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JOS ADDRESS'--cZZ6-,�-, SA��'i '��.' �— <br /> PERMIT4k" <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affr,•m that I am licensed under the provisions of Chapter° (com•'riet7Cirto with Section 7000 of Division <br /> 3 of the Business and Protessions Code,and my license is in full force and effete. <br /> License �� ZZ� --- Expiration Date OAG4. <br /> Date p/ Contractor Aw,H k cfoDZ57-1 _Y.h2ts�7<4f� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm that I have a certificate of consent to serNnsure, or a cerffmate of Workers' Compensation <br /> Insurance, or a certified copy thereof(Sec. 3800. l..ab.C). <br /> Exp, pate <br /> 9 Company 1317 <br /> ,�Certiiied copy is hereby famished <br /> Certified copyU..Ii ed with the County Building inspection Division . <br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPJZSATION INSURANCE <br /> ghis section need not be=Meted,if the permit is for o.'-e hundred dollars(s,.t)0)or less) <br /> I certify mai in the perforrnsnr�of the wont for which osis perrrit is issued.I sho not employ any peen in any manner so <br /> as to becorne su*.r.-to the Workers'Compensation taws of C81� <br /> Date " Applicant <br /> I NOTICE TO APPLICANT:tf,afoer making this Certificate of Exemptior4 you should become subject to the Workers' <br /> Compensation provisions of the labor Code,you must forthwith carsply with such provisions or this permit shall i <br /> be deemed revokeii. 1 <br />