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7-27-1999 8:20AM FROM FISCH ENVIRONMENTAL 2097723571 <br /> 7-26-1999 2:58DM t FROM <br /> r� <br /> .� <br /> I <br /> � jOBAVDRESS, � ( �runnloA PERMITlt: <br /> j LICENSED CONTRACTORS DECLARATION <br /> I <br /> I hereby affirm that I dmlicensedunderthe provisions 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 /> j License/-#7 M'34(o j Expiration Elattet� I - 31 •a00 0 <br /> Date Contractor <br /> Signature / ; I <br /> i I WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations. <br /> ? V I have and will maintain d Certificate W Consent t0 self-insure for workers compensation,as provided for by <br /> Section 3700 of the Labor Code,for the Wormanae of the work for which this permit is lsvmd. <br /> 1 have and will maintain workers compensation insurance.as required by Section 3700 of the Labor Code. <br /> for the performance of the work for wri mn this permit is issued My workers'compensation insurance carrier - <br /> �. and policy number are: <br /> GamerCMOAIAI(� POlicy plumber 155101225-2? <br /> FA <br /> I certify that in the performance of the work for which this permit is issued, I Shall not employ any person in <br /> any manner so as to become subject t0 the workers'COmperl5ation taws Of Califomia.and agree that if t <br /> should become subject to the workers'compensation provisions of Section 3700 Of the Labor Code. I shall - <br /> II` forthwith comply with those provisions. <br /> 1 IDale 7C] Signature: <br /> I WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> I'OU."O),BOIN ADDITION TO THE'COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF, <br /> j THE tAR CODE,INTEREST,AND ATTORNEY'S FEES. <br /> i <br /> i <br /> E <br /> f _ <br />