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07/14/99 18:52 FAX "11 <br /> rI <br /> I <br /> �r <br /> JOB ADDRESS: ii �( r PERMIT#: ; <br /> LICENSED CONfF ACTO S DECLARATION <br /> l <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 full force and effect_ i <br /> Incense, _7 2 0 9 0 4 Expiration Date <br /> ' Date June 10, 1999 Contractor Jody A. Vickery <br /> Signature <br /> WORKERS' COMPENSATi N DECLARATION <br /> I hereby affirm under penalty of perjury one of the following c eGalarations: <br /> D I have and will maintain a certificate of consent to self-ins re for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of Me work for which this permit is issued. <br /> r I have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance Carrier <br /> j and policy number are.- <br /> Carrier <br /> re:Carrier Golden Eagle Policy Number Nwr 94455 <br /> I <br /> © 1 certify that in the performance of the work for which this permil is issued, I shall.not employ any person in any manner <br /> so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to <br /> the workers'compensation provisions of Section 3700 of the Labor Code. I shall 196with comply with those provisions j <br /> Date June 10 , 1 999 Applicant J <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,000),IN ADDITION TO TETE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />