Laserfiche WebLink
' �-27-201 11-51 CAt'TBRf A INC -- <br /> 1707 935 6519 P_02r02 <br /> JpB ApQRr_SS:.,$5(p V}GA-� Rat, -, L-oaU PERMIT#: <br /> 00 Z � <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I arts lrcrnsed under die prons+oews of Chapter gr(commencing with Section 7000 of Drvisron <br /> 3 of the Susrness and Prolreasiona Cone. and my grensa is in full force and affect <br /> F_rcanatt to Expiration Uwe <br /> Data _ n 31 of <br /> Signature <br /> WORKERS' COMPENSATION CECLARATION <br /> 1 hereby afffrrn under penalty of penury one of the 101lawfnir decztarauons. <br /> ❑ I have ana will rraintaJn a canificate of consent to srtf-(nsure forwnAcefs =)rnpenxatwm as provided far by <br /> Sectian 3700 of:Tie labor Code, for the perturmancm of the work for which this permit tz lasued <br /> 91/1 have and wfil rnalrrtarn workers cor vensanon ir*surancm as required by Secuort 3700 of the Labor Code, <br /> far the pefTormance of Oe work for wnrch this perrmt.is rs3uad- My wor1rerS'c orrtprn_-A"n. rnsurancC cam r <br /> and policy number are- <br /> . CameraINA POJ" NumDff <br /> ❑ 1 ctrrO l(hat fn the pttrt:nrance of the v.orx for whyo rhes Pffmct is 5Tred.I shag not employ any Person in ant►manner <br /> so ac ro become subject la me*..miss =maensamm tris of Co famta and agree trrat if t&houfd become sueject to <br /> tree workers con+pen.-pabon FTYL-sons of Section VW of Ile...ober Code I shall tanh wfth comply unt+M*60 araws,ons~ <br /> Date Applicant <br /> WARNING.FAIL URfr TO SECURE WORKERS COmPIENSATTON COVERAGE M UNLAWFUL AND SHALL 3UBJeCT <br /> An EMPLOYER TO C;0MIr+AL I GXALT(ES AND QVIL FINes VP TO ONE HUNORED THOUSANC) DOLLARS <br /> (100.000), IN ADDITION TO T"r=COST OF COMPeASA nC)".DAMAdE3 AS PROVtDEU FOR IN StcmoN 3706 Ofa <br /> THE LABOR C04t~INTEREST,AND AZTORtrrtY-5 FEM. <br /> • <br /> TnTat o raa <br /> Z�Z 26ed <br /> If) S L til IP-Tnr `?npn DLP c7F ' OUT `bUT 1Sa l 9 BUTTTTin 66ain ,ta I uac <br />