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JUL-31-2001 08 39 CRMBRIA INC 1797 935 6649 p 02/02 <br /> i � (,�� <br /> .SOB ADDRESS• `1-100 MQr arA COI&V+ C,1�+r1PERMITO: 002^7 0 3 1 <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the prmiskxis of Chapter 9(CornrnwcFng with Section 7000 of DEvwion <br /> 3 of the Business and PrO&sshona Cade and my Icense m in iull forte and erfect <br /> License # 9xPiranen Date <br /> � <br /> Data Ccsrrtrac;or <br /> /�r � <br /> /!/1►Je itQr�Y/l s <br /> s►gnature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under p"alty of per)ury one of the following doca4ratlans- <br /> ave and will maintsfn a certificate of consent to 3etf4nsure forwarkers compensadon Ali provided for by <br /> Section 3700 of she tabor Co4e. far tete performance of the work for whi l this permit Is(xtued <br /> Kfohave and will maintain workers'coripensaninsuranceinsurane as required by Se=n 3700 of the tabor Code <br /> r the performance of;he work for which iE11S pt_�r7rvt is issued AAy workers'aomoensat�an insurance carrier <br /> and policy number are: <br /> Lamar i2�& 4( 1%rkP_l Policy Number._ <br /> i ❑ l certify That in the perlimPance of tha worx bar whcrch do permit Is Tssuod.I shah not employ any onion in any manner <br /> SO as to t)*'Came sublecr to the wcrkefr mmpehsanon Lavot Of Califomisi.and nme that dl.should bom, sunlec,to <br /> thO wo"m compenssuen pio►isions of SecUor,3700 of the-abor C I ah 11 f rth►nth comply nth these pr+ovis"Orm <br /> Date AppliCaJA <br /> WARNING-FAILURE TO SECURE WORT tzRS'COMP6NUTION COvfRAnLr IS UNLAWFUL.AND SHALL SU9lECT <br /> AN RampLOYLR TO CAIMPIAL eENALTIEFS AND CIVIL,FINES IJP TO ONE HUNDRE-0 THOUSAND DOLLARS <br /> (100,000) IN AOOITION TO THE COST OF COMPENSATION DAMAO;ES AS PRQ'VIDED FOR IN SECTION 3706 OF <br /> THE LABOR COp1Z.JNTI`REST.AND ATTORNWr3"M <br /> f <br /> Z/Z a6ta ',CO Ol t0- LE-Uf`ZOEO pLe SZ6 ` oul 16urtl5a-L V 6u7T7.tf3 567)j0 Mfg �uag <br />