2007-2695 E KATELLA AVE("W4
Permit Types
_•••• --a wn WCULMMTION:
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:
1 have and will maintain a certificate of consent to self -Insure 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 performance of the work for which
this permit is issued. My workees Compensation insurance carrier and policy are:
Cartier. STATE COMPENSATION IN U ANNE FUND Policy No.:90 0 3 6 nn�a
Agent 76 Expiration Date:11
Name of
Phone No.:
I certify that in the performance of the work for which this permit is issued, I shall not employ any pe 80 in any manner so as to become subject to the
workers compensation laws of California, and agree that, it I should become subject to the workers compensation provisions of Section 3700 subject
the
Labor Code, I shall forthwith comply with those provisions.
Signa of Ap . nt l/
Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of perjury that there is a construction lending agency for the perform
(Sec.3097.Civ.C): ance of the work for which this permit is Issued
Lender's Name:
Lender's 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
Contractor Sig, ature
NUMBER EXPIRATION DATE LICENSE TYPE cec
870828 01/31/2024 B's
./
Date