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9-22-1999 A:01PM FROM V. a <br />JOB ADDRESS: / 313 E..)PERMIT*: 00 (Z-L 4 f 9 <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 # CS7 La-ritt-i Expiration Date 0 I 13//c' Z. <br />Date G II r /ot Contractor 61er, 024164 resth;zr <br />Signature <br />WORKERS' WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following decalarations: <br />0 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 />Corner /PaCk i ParEef Policy Number We# ./...re, arg0 <br />CI I certify that in the perforrpance 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 should become suoject to <br />the workers' compensation provisions of Section 3700 of the i...a.•r C-cie. I shall forthwith comply with those provisions. <br />Date G fificy i Applicant e# 404 / . gedital,_ <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CiV1L 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.