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JOB ADDRESS: ji(>>°��LJ eaz,d ��J�^� , 5 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 full force and effect. <br /> License #-495-1& Expiration Date <br /> /D Date ontr for <br /> Signature <br /> ORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations- <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> 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 /> and policy number are: <br /> Carrier��� �11rn/� <br /> Policy Number <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if I <br /> should become subject to the workers' compensation rovisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date �-1J� Signature., <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSAT COVERAGE IS UNLAWFUL, AND SHA L SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. <br /> C "J <br />