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JOB ADDRESS: <br /> <br /> PERMIT*: <br /> <br />LICENSED CONTRACTORS DECLARATION <br />I hereby sfnrrn that I an, licensed under the provons of Chapter 9 (commencing with Section 7000 of Division <br />3 of the Business and Professions Code. and my ftcense is in full force and effect <br />License *,5-511/ <br />ExpiratiOn Date <br />Date —12La512.2_______ Cant-actor lie,5Y-77471.2,..---X• //1-1P-5 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm that I ha <br />Insurance, or a certified <br />Exp. Date 0 I-Voit-7-1)60, <br />Certified copy is hereby furnished <br />0 Certified copy is flled with the County Building Inspecton Division <br />CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE <br />gent to s.elf-insure, or a certificate of Workers CompensetIon <br />c. 3800, Lab.C). <br />Company 1/-a„.c)Cite_ <br />(This section need not be cornpleted, if the permit is for one hundred dollars (5100) pr lass) <br />I certify that in the performance of the work for which this permit is iSSLOSId, I shall not employ a <br />as to become subject to the Workers' Compensation Laws of California. <br />Date /-1/z1z2??. Applicant <br />NOTICE TO APPLICANT: If. after making this Ca floats of Exemption, you should become s <br />Compeneation provisions of the Labor Code, you must forthwith comply with such provision* <br />be deemed revoked. <br />the Workers' <br />rmit shall <br />person in any manner so <br />FROM - West Hazmat <br />FAX NO. : 19166388613 Dec. 27 1999 01:16PM Fl <br />TO/I0 39Vd <br />NO_DIDOIS 39V BITIL9VEK <br /> <br />666T/LUZI