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'14/99 09:59 FAX 4102 <br />JOB ADDRESS: <br /> <br />25]-2— kik/4,1(4-10o (2-04.44 PERM1T#: Ot? 3 ct <br /> <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 # 7 2 0 9 0 4 E-xpiraticn Date 4 / -4n/on <br />June 10 , 1 9 9 9 Date Contractor <br />Signature ./,'X':it://0 -K>11-7.2."-e,-,1 ,7 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following decaiarations: <br />ID 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 Golden Eagle <br /> <br />Policy Number NitAIC 5 4 4 9 5 9 — 0 4 <br /> <br />C I certify that in the performance of the work for which this permit 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 shouid become subject 10 <br />the workers' compensation provisions of Section 3700 of the Labor Code, I shall fwith comply with those provisions. <br />June 1 0 19 , 99 Date Applicant <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 THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br />THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />Jody A. Vickery