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V08/30/1999 14:1@ 0000000000 = PAGE 02, <br /> I <br /> I <br /> I <br /> JOG AD0RreSlt: la11r� ,� PrRMiTN: D2d <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby aflm dear t am keftsed unftr the piavtsieft of Chsaw I icorrrmenOng with SWIM 7V00 of Qiv Sion . <br /> 3 of the Bwtarss am ProMscOns Godo.and rely tioanss is art u farm*and eRset- <br /> I �•License N ErrpKitio►t Data ' <br /> Signator. <br /> WORKERS'COMPENSATION DECLARATION <br /> I"few a"under penalty of perjury one Of Me todo"dadarabont: <br /> i <br /> i have and witl niairrtais a"rOfk*W of consent to self-insure for workars c=portWWn, as WMWW for by <br /> Saction 3790 of[hie Labor Code.for the pirtorrr+ance of tfw wo*for which thio permit is armed. <br /> I hsve and will maintain workers'aampensativrT insurance.as required by Section 37CO of fhe[.agar Case, <br /> for the pefiorman[:e of the work for whicA Lhti perrait is isauftd. .My workers'COmpensation insurame Carnet <br /> *no poppy number are. .{ <br /> lir 1 <br /> LL(�CJW�1 <br /> Csr - Policy Nufriget <br /> �.LL,. - <br /> I Ca"that In the pWorrrianct of the wdk for which this pw rust is issued.1 shall not empty any Persian in <br /> any manner so as to become subplot to tyle workers,owim "tion laws C agree that it I � <br /> should boom*subject to the wotftpr0'o0n'spansfneo of a!. Cade.I shall � <br /> 1DrthrO&Wv with erom previs-ans- <br /> Da signtu <br /> MIEARX1 IUW TO SECURE 1MORK R$,,COm rE TtOx COVI:"Ge is t1M.AWNUL.AHED t*^6JL$UBIECT <br /> i I <br /> AM EMIltOYWX TO CRrM11NAL PSNALTitf�AND 6 V►TO ONE HUV40RKD THOUSAND t]OL.r.ARX <br /> pn.ow).in AO TW"TO TW9 COST OF COM .Dm"026 As PROVOED FOR 11E$ECTIOR$706 of <br /> Thr tAMOR COM,IMTERIOT,AND ATTORKEar's PER$. _r._,.._ <br /> 1 - <br /> 5?f <br /> 2�3 <br /> A (v��33 '0" <br /> ,. <br /> k I ia rvgtf trrvr 8 t;6a i- -c <br /> i •�{ wC)2i� �id80=� 666 I-0E-8 <br /> I�I� <br />