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12/10/99 16:47 FAX <br /> 09-57?- '26 MODES fU ATCPAGE t3 1 <br /> ." , t AM Fi <br /> f iN.ietyuln Cosrni r ,van IV TI14riV er�nit <br /> i A ter'" s e.a �� alort J nt <br /> ? JOB ADDRM; <br /> j �'� PERurr Saw: <br /> I ffI <br /> i <br /> LICENSED CONTRACTORS DECLARATION JLCQ) <br /> i <br /> j f h"hy SOM that I aim liaenaed Uhdor the pewiss of Chapal 3 " n(eenm o;rg with Sacian 7000�of 7+viscnasqrOmbiOng <br /> OOde and my hounse is in full force and*%CL <br /> Lim"* ?0!L,.�_�..Expiraeion <br /> � 13aW Contrse>aer, A Lia— <br /> - .�.••,� <br /> ' hOrtialtrr+a: z rim. <br /> i <br /> WORKERS'GOMr!'I UT10N VEG""TION <br /> I hereby affirm <br /> under perilrlty of poury ono of ttta%00"*d4U nrdons; fCld- AU-TMT A'►L'fj <br /> flaw anal wad nTaintain a C�rtfffCab of Co""t b GO :Iriaurr fer workrra'corr"nration, as provW*a tow Dy ff <br /> f secdten 37pp of the 6.abor Code. !as the per%rmanps of the w wk kwwhich this pemrtt is isaua!!. <br /> f <br /> I mare aria vrili M001110M 1vaHi OW edmponsaftm insurance. ss rrguirad by SoMn 3700 of+the 6OW Cold. <br /> }or the P mw.&Of the work far which th a pern*is loomed <br /> . My 1MOrttari'a Ripartsaxior+ irwranrlr <br /> i earns►and miry 14Yr*q"are: <br /> I <br /> i <br /> Gi1'1'IeF: rOC._.._�..,_ r Mranber. f <br /> ti GOq'tifY'gat In a* + <br /> perAdrrriarrea eT the u►pAC for his plrrnit±+s isauad, 100 nvt employ tt►p per*or+ in <br /> erry r+taAliar eo as to tie�are�stmt yo J'ii Wtii Hifi't;OeRbRliiWOA Owl Of CaEdamia,and agree that if i <br /> stioirit#becdrrie 1Fi ifi{ect to tt+e Work"0MParisri xx—puwisicns aR SeCiion 3M Of ttie Liiibor Coae, i sh* <br /> tltwith C0MP1y with 1ha t pmvitaWt <br /> .Date, Ste: T <br /> trirrtt d Name: <br /> i <br /> WAi1✓M1I"al P;MLV l!TQ:fir RE WOI[It�11$�C14i1�IMNATON COVERAdW f$UNLAVWUL,AND SMALL SUBJE r <br /> AM 9WLCVIP TO CflkM%^L PRUALTiRG,AK5 Crest.orlMag W To OM ULMOM'!"4&4A, No tsO 6A.ARV <br /> j ($180.p00_), IN ADOMom TO THI WOT CW ATlt3K IWME.iT.ATrOPWIY' <br /> PR "M AND DAMAQrB J1$ <br /> Ob1D$O FM Of 4WTTOM 1701 OF TW L^WR COW. <br /> !' C•tt7 Nseri«e1l sYtlietlaed repr#IwrfbrUwf. <br /> "grow � <br /> eYtthOf+�e � <br /> is slyri 1Ais i .iaayehrn Corm lMdi 900MM AMpssatls+n On nay bohM i wni%evtand tr.iu 46Yt�l01'iiattiin YsiW fer <br /> 1ser and Is smitbd b the rrarlr plan OW"on awof this srMNiantion. ^�. <br />