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09/_15/99 WED 13:39 FAX 510 663 6350 GEOItATRIX OA LAND X005 <br /> Y <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provWons of Chapter 9(commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code, and my license is in full force and effect, <br /> License#1Q �Q Expiration Date <br /> Date ' <br /> Co tractor�� - �101 �A'Nl PVI <br /> Signature ` <br /> WORKS OMPENSATION DECLARATION <br /> hereby a rm under penalty of perjury one of the following declarations: <br /> I have and will maintain a certificate of consent to setf-insure Ear workers'compensation, as provided for by <br /> Section 3700 of the Labor Corse, for the performance of the work for which ibis permit is Issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance carrier <br /> and policy number are: T� <br /> Carrier�Lki N Y , Policy Number <br /> I certify that in the performance of the work kw which this permit is issued,i shall not employ any person in <br /> any manner so as to become subject to the workers'Compensation laws of Califamia,and agree that if 1 <br /> should become subject to the workers'compens7*jA7X-4t,-14-;�-'.�r- <br /> WARNING: <br /> isfons of Sectio 3700 of UNs Labor Code,i shall <br /> forthwith comply with those provisions. y - <br /> __:.s5lgnature•FAILURE TO SECURE WORKERS!COMPS SATIONICOVERAGE13 tai L,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML INES UP TO ONE HU)b QUSAIVD DOLLARS <br /> (100.000),IN ADDITION TO THE COST OF COMPENS ON,DAMAGES AS PROVIDED FOR IN SECTION 3746 OF <br /> THE LABOR CODE,INTEREST,AND ATTORNEY'S ES. <br />