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06-15-1999 01:37PM A TO <br /> 15102333204 F.04 <br /> JOB ADDRESS: /07 1,0 otrkr.la. PERmITr: <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 o the Business and Professions Code, and my license is in full force and effect <br /> License I 7 -o 3 Co 3g r] Expiration Date <br /> Date 7/a19'? Coniracror Qt eClStOo %c at;etita <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm that 1 have a certificate of consent to self-insure, or a certificateofWorkers'Compensation <br /> Insurance, or a certified copy thereof(Sec. 3800, Lab.JC)- L' 'Exp Dam -z � 16Company L -e Fu"CK <br /> T2-Certified copy is hereby furnished <br /> O Certified copy is filed with the County Building inspection Division <br /> -CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br /> J{This section need-nbt be completed, if the permit is for one hundred dollars(5100)or less) <br /> ,. I certify that in the performance of the wofk for whidh this permit is issued, t shall nm employ any personin.any manner so <br /> as to become W*cl to the Workers' Compensation Laws of California. - <br /> Date Applicant <br /> NOTICE TO APPLICANT-If,after making this Certificate of Exemption,you should become"jecr to the Workers' . <br /> Compensation provrxions of the labor Code,.you must forthwith comply with such provisions or this perinil shall <br /> ._ be deemed rvvoked.: : <br /> TOTAL P.04 <br />