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JUL-27-2001 11:51 CAMBRIA INC. 1707 935 6649 P.02/02 <br /> JOB ADDRESS:,_ <br /> V i C41T �• "CU PERMIT#: V 0 27 o <br /> ,�. <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000 of Divuon <br /> 3 of the 9usiness and Professions Code. and my license is in full force and affect, <br /> License 10 n 7_ Expiration Oate 01 1 :61 -1 Lo <br /> Date 7 31 aj Conuvctor L042Q -cn (�,- 4-yi-— <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of penury one of the following de<zlaradorts <br /> ❑ 1 have and will maintain a wrtificate of rmnsent to sett-insure for workers'compensation. as provided for by <br /> Seaton 3700 of the Labor Code, for the performance of the work for which INS permit a Issued. <br /> 61 l 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 hermit s issued. My workers' compersation insurance carrier <br /> and policy number are: ((''�� ``/, <br /> Camer DQ A � Y�.�,C�n Policy Number <br /> i O 1 Corti F/that N the perforrrl n of Ne WOO for which this permit is is6ued,I shall not employ arty person in any manner <br /> so ac to become subject to me�orkers' Compensavon Lams of Califomia,and agree that if I should Demme subject t0 <br /> me woncers eomper% at»n pravrsions of Searon 3700 of me'-3bor Code. I stall fent with tblnply with diose orovisrons. <br /> Date Applicant <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL,AND SHAL15UWECT <br /> AN EMPLO'rER TO CRIMINAL REMALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAUES A3 PROVIDED FOR IN SECTION 3706 OF <br /> THE LABOR CODE. INTEREST,AND ATTORNEY'S FFES. <br /> TnTnl o P1 <br /> Z/Z a6ed '•/0:9t 1.0- lE-Tnr' '.ZOEO ex 92!6 ° 'ouI '6uTlsal g 6uTTTTJ❑ 66@J9 :AS 3ueS <br />