5814 E CAMINO PINZON (3)Permit Types
wm Of%114JR DECLARATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self4nsure for workers compensation, Issued by the Director of Industrial Relations as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
I have and will maintain workers compensation insurance, as required by Section 3700 of the Labor Code, for the
this permit is issued. My workers Compensation insurance carrier and policy are; this of the work for which
Cartier. MAR COMPENSATION INSURANCE FUND Policy No.: OZ84018
Expiration Date: "140023
Name of Agent:
Phone No.:
I certify that in the Performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the
workers compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
,,.,"Labor Code, I al rthwith comply with those provisions.
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Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby Minn under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is Issued
(Ssc.3097.Civ.C):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is In full force and effect.
C tractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (SI
1070058 10/31/2024 C39
Ir
Date
Date