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08/16/1999 14:35 9167379 �\N LUSH GEOSCIENCES PAGE 02 <br /> n <br /> V <br /> QC flu's 9 HFI 10: 5 1 <br /> ) <br /> JOB ADDRESS:�� ��, (��/t�lliS _ PERMIT*: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the prowslons or Caapter 9(commencing with Section 7000 pt Owrsrorr <br /> j 3 Of the SUSIneSa and Professions Coda_ and my ticenSe,S•n Lull force and ef'fleoL <br /> License t Exptrabon Oats rte—LL-EL O <br /> Date —�—� �tractor /—i SG 14 /1 v'I f2 0 Yi M f Vl�j4 <br /> Sgnaturs <br /> WORKERS, COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perlury one of the f011ow1119 decalarabunv <br /> I have and will maintain a certificate of Consent to se!Rinsure'or wor•.cers'ccmpensatton, as provided for by <br /> Section 7700 of the Labor Code. for the performance of the pork`or which this permit Is Issued. <br /> qv nava 111111 will maintain workers'eomDensaban insurance, as reputred by Secnon 37,00 cf o e Uoor Code. <br /> I for the performance of the work for wh cn this permit,s slued My Ncrkerrs compensation nsurance carver i <br /> and policy nym er ale: <br /> Carner 10 Policy Number .i�LQ _ <br /> Cl 1 Certify:hat m the pedcrrnance Of the wont ler wNOn this Perms it is3ued. I Gall not em <br /> eo as to become sub'eat to the workers' 7Om PbY hcuany Person m any manner <br /> I pen 3706 laws Or CahfCmq.ani;agree that d 1 inoula become aublsd to <br /> tha workerY':Omoensatron prpvlaionl of Section 3700 OF the, C;ae. shall Porthwrlh r-0mply wdh tYroee Proviswna- 1 <br /> Date Applicant <br /> I <br /> I WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL„AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE RUNDRED THOUSAND DOLLARS <br /> L (100,000), IN A0017rION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> TME LA80R COOS,INTEREST,AND ATTORNEY'S FEES. <br />