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JOB ADDRESS: Rao( N• WS' ,ane. S-ia K+-0rt PERMIT#: <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 lull force and effect. <br /> License 90z?- Expiration Date, 30 Na J 59 <br /> ry <br /> Date !z N" 93 ,> Contractor - Ehve� a r°��' <br /> ' <br /> 'WORKERS' COMPENSATION DECLARATION , .T.. <br /> I hereby affirm that l have a certificate of consent to self-insure, or a certificate of Workers' Compensation <br /> Insurance, or a certified copy thereof(Sec. 3800, Lab.C). <br /> Exp. <br /> Date t0l 6r-f- 9 Company 51k Xe 6v.`,o-e"a. e" Z.i s L e%s4 re f wK wl <br /> ertified copy is hereby fumished <br /> Certified copy is filed with the County Building Inspection Division <br /> : CERTIFICATE OF-EXEMPTION FROM WORK RS' COMPENSATION INSURANCE <br /> (Thissectionneed not.be completed,if the permit is for one hundred dollars (5100) or less) �. <br /> I certify'that in the performance of the wor!f r which this pjR it is is ued,l shall Edi employ Ky prison manner-so x` <br /> as to become subject to the Workers'Compensation Laws of California. x <br /> Date Applicant <br /> NOTICE TO APPLICANT: If, after malting this Certificate of Exemption,you should become subject to the Workers' <br /> Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall <br /> be deemed revoked. <br /> 4 <br />