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001 1-4. UUUUvUUvUUU <br /> .ItIECEIVED <br /> AUG 12 1999 <br /> EnlvIRoNME,1141AL-MEA •Tr <br /> JOB ADDRESS: ly2 � PERMtY#t: <br /> LICENSED CONTRACTORS DECLARATION <br /> aft[rm that I*m Ilcertsed under the ptbv4siona Of Chaster 9(cornnwmcing'►1'Stiction 7000 of Division <br /> 1 Hereby Ireense is in full force and effete <br /> 3 of the Business aM Professions Coae.and my ' <br /> License ax Expimtjon Dau <br /> r <br /> - Date—*4Ql� Contra=WORKERS' COMPENISATION DECLARATION <br /> I hereby S*m that I have a certWIc*e of consent to se"sure, or a certificate of Workers'Compencstlan <br /> Insurance,or a ceftMed COPY therrof(Seec.3800.Lab.C). <br /> EYP. Date CoMpeny <br /> D Certified+SPY is hereby furnished <br /> O Certified COPY;s filed v^'0 the County SuHdift inspection Oiviean <br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE <br /> (This mclion need not be completed,V the Per*is far or►f tmuntlrad dollars 100)a lassl Person in any manner so <br /> I cartify rm <br /> that in the woanoe of the work for whid�this Perrm is mumd,l shall not empay any Pe <br /> as to become awt Jma to the womers'Cotrrpensation Laws of CalHomis. <br /> Oast Applreeru <br /> NOTICI TO APPLIC"T:N,of o-making thts Cartificata O!Exemption,you shouitl secoM!tubjact to time Workers' <br /> compensation Provision of LM labor Code,you rnuxt fdrthwith comply with such provisions or this Permit shan <br /> be deemed revoked. <br /> i <br /> . .. ...N .1:3.:iJ.'r=t1\'.„�. 'r M.p...Mau..1M .:V.��%�M.�.�.•... -... i . ✓ ,. T1f .. .. a .�... w ' , .. . . . <br />