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APR-14-2000 12: 15 FROr—aREC I S I ON SAMPLING TO 12094683433 P.02 <br /> r 755 41, <br /> Lo <br /> kti�I•�4'����5_ ;'wi'evF' ���u =rrrt.W a-s`:�, ���-,.. ni+y� •1 _�� �} .r.::,..,..'..: p 3 QY+�� <br /> i _ <br /> ..Yrs<llti�'r.._ :1-rti15eS��g`?�..?il4wLSt�A:4 J.i;+f—s.p ='� �" YHeI: ���' .�, r_�: � @�p.!• .:. <br /> " � <br /> -e ._�d�—�_.L Nri�rarr.C.�r .' �.1 s _F:::C=:.f�"• l�A:.:''y,4 rY�� � .I <br /> Ips �flri�•�., ."'::jt�.i3..�,;°�rp�� +z '� � a ,P i�rIJ7'Oi7r�i7r�sa� ,�`•�+'`'�".r+ �saeea.-m=c�i�, '�1'YS,. ��'� s. p r�� ._,r <br /> Af—..... C- .'•R ....r.f 'C .. r .. —— ti _ 7 C "�' .�':GM'Nu'e�,. F.-? ('r�` <br /> LICENSED Ct3NTRACM S DECLARATION 4,.CD} � <br /> I Hereby affirm that I am ricensed under the prayisittm of Chapter 9(commencing with Section 70oa)of Division <br /> 3 cf the Sus'nc=and PrOft= %Cndir--,r,d my license is in full force and effect. <br /> t rtsc / 6363 , ] Explraaas,03W: - 1/312-ods. <br /> Contractor rQ c. r v v uvL l(A . <br /> THie: <br /> FTtPltBip nam; _v -- CLQ h L Q-9, <br /> W0"9RS'CWPENSAT1GN DECLARATION � <br /> I MTlsteby affirm Under pera)ty of perjury one of We fodl0 r"dedarations: (CHM K ALL THAT APPLY) <br /> I have and vsrils maintain a cerft=te of consent tni self-insure for workers'compensation,as provided W by <br /> Section 3740 of the Labor Code, for the pedbrmar;ce of the work for why flits permit Is iftuect- <br /> I have 2nd wit maintaln workers'compensation kmurance, as required by Sec#an 3700 of the Labor Cade, <br /> for tyre performance of tate work for which this permit is issued. My wworkere conipensabon insurance <br /> carrier and poiicy numbers am' 1 <br /> Cartlef: Potatcy Number: / ZZ I O C) <br /> I mmti(y%at In the perfbrt 0f;ft Of tho vmrk for which Itis permit is issued,i shall r)*t employ any parson In <br /> any rnonner so as to becarne su*KA to Ux workers'compensation laxer of C;a1'ifiornW and agree tut tf I <br /> should become subod to the workers'compensation prnvisims of Section 37W of the Labor Code, I shay <br /> forthwt1t►comply with tfi=G provisions. <br /> ire: i'�getads+na: <br /> Printed NaaW. <br /> WAR NtNC@ FAILURE TO SECURE WOJRIU aS'CO MPEt1tSA4TIGH CO}FNA®E IS UNLAVOWL.AND SHALL SUajr-CT <br /> AN E14PLCWM TO CRMMAI.P5ItALTIE$AND CML FW65 UP TO ONE HU NDRW Tf OUSMD DOLLARS <br /> ( 9 W,LOi <br /> IN AMITION TO THE C*ST Or C04IFfMATHK INt EST.AT7 t�lit�9Y0S Fen,Add[)RAEtiA4G�S A9 <br /> PROVIDEDRW IN S ECTM 370&tip THE LABOR COM <br /> 0-1 c.:lr H..�authorld w r min vej,hereby <br /> tp�grf Rfsls San.rrsaqutn Causailr W�lI F'ertritglCeatdom on rtryr b�dtalL 1 unstar=mr,�Rlele mon Fs Ya➢id for <br /> arse 1 err and is united to the work pinch dated on tho r,"t W9 of d iiR applicapion. <br /> hA it'd 2lOLrld }iL-II,d EEb£89b6BZ $9:#'t; 808Z�LTlL� <br /> TOTAL P.02 <br />