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Mar-20-2001 01:57pm From-BROWN AND WELL 9494740940 • T-770 P.003/003 F-038 <br /> rY ' MI -11, <br /> ' l� a` i i�, !�`�-.- 4 r' <br /> UCENSED CONTRACTORS 05CLARATION (tel <br /> I hereby avrsn atst 1 am licensed under ms promws of Ctilrptsr 6(wnunnrK*,y will,3&cAkA)7000)of rtivi>Jurr <br /> 3 O#te 9u&w.,A and�Frobastane Code and my license is;in full A�rna and&hart#nn <br /> License ir: r1l��i y� I Exphiflan Date: 1 l I of _ <br /> oattx ' COntracica: �il or`1t <br /> tlipreaffrsa: / TYM y_ <br /> Prfimea Ing M; Ch1[iiA, c V. Ge S <br /> WORKERV COMP MATICN DECLARATION <br /> I hereby&firm under penalty cf Perjury arta of tlra ft4mwe declarations: JGMCK ALL THAT APPLY) <br /> I have and will main"a clmmnm,a 04 canecnt to sMINInaure for workers'cornpansaw.as prc.�for by <br /> Smobw 5700 of the Labor Code,for the parkmiance of ttw work for which this perm is issued. <br /> 1 have and will maintain*=kers'oanpensafion insurance,aa;required by Sedfan 3700 of Itra Labor God&, <br /> for th9 Pedormanoo of the work for which this pemut is Lmsued. Ny wortcers'rxmp®usarkxl bnuraam <br /> carrier and poYry nuatbefa are: <br /> 6afrier.�{ ,��7'� M UTLI/�i POB�ye flufrrbar: Gl- - 072 Gf _ <br /> "P41 M"the"in Ura P& m,anoe Of the work krr whidt this permit is Issued, I shall not employ any Paxson in <br /> tiny nrmnner so as to Woww subject to ft w0deW COmpensatl0n laws of Galitmia,and agree Met if I <br /> shculd bacarp subject b the wartier$0ornp*mwticn prwmiaia cf swoon 3790 of ttrs tabor Code,i shag <br /> f0fthWdh ear"+with*KW prov*Jorre. <br /> caa: tGl bl � ,� <br /> Printed Name: h n t y.agg —4^6.-f�r--v—��--- <br /> WARNING!irAILURE TO SMUft WGRXaW l.OW"SAT101e t;L1VERgG£ r6 UNLAWFUL,AND SHALL 8eJ11JECT' <br /> AM PUKO1r1?R TO CRWL*L PENALTIES AND CML FIMIM UP TO ONE HUNDRED,THOUSAND DOLLAM <br /> tSI Od,ep4L Ui ADOMON 7D THE C=DF 001111'ENSATION,INTERN,ATTORNEY&n=,AND nA GES AS <br /> 12ROVEW FOR IN SHCriON 3706 OF T14G LABOR CODE_ <br /> NONTsad mumwbod <br /> 7ePnmWnWeivai. IwraL>lr <br /> stxhortpe______ _ <br /> so-aign errs son lamgrirt CauMy YW�1 PetmNr Appacaffon vn mY 4trreNf. N unopnt"tela <br /> tit>or11rd6Gl Fr v9Lid for <br /> ane 1 rand ie trribd rp tM work plan dated m the f►ant__�wBe or this fon- � J <br /> 7a �lltl.J ynf14 u, JTI <br /> CcoCga*.�q] Fa:TY aOa9 ITT Lara <br /> TOTg1_ P.02 <br />