Laserfiche WebLink
JOB ADDRESS: `t/ 0(0 emor1>4 S -j, e-� PERMIT#: <br />S7aKTov, C{ - <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 # Expiration Date //1-;12 , i <br />Date Contractor A �? <br />Signature ! -Z <br />ORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following decalarations: <br />❑ 1 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 5 7-V C Policy Number l K7 t% " LV <br />❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in anv 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 fo hwith comply with those provisions. <br />Date (1. (- Z / - �cl Applicant e= <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION / ERAGE 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 THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br />THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />