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Feb-02-00 10 : 08A VIRONEX, INC . 5102660963 P .01 <br /> sent uy: rnoenix National Laps; 602 804 1179; Feb-2-00 7:38; Page 111 <br /> • � LICENSED CONTRACTORS DECLARATION (�,fwp} <br /> i hereby affirm that I am Iioensed under"provisions of Chapter 9(comnvrxing with Section 7000)Df ONIsion <br /> 3 of the Busineu and Prafessions Code and my license is in full forst and effect i <br /> License 0: �7 LLQ + Expiration Daw �,L_31 � l <br /> Data: ContrxSpr: C) <br /> Signature - �L�..�..�_T7tle: <br /> Printed name:—::�S <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of Ov following derivations: (ChIECK ALL THAT APPLY) <br /> _I have and will maintain a ceTtincatie of consent to self-lnsuro far workws'Compensation, as provided for by <br /> Section 3700 of the Labor Code,for the performance tN t)te work fox which thls permlt Is"," <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Co*, <br /> for tho performance of the worm(for which this perf+mit is issued. My workers' compensation insurance <br /> carries and pocky numfl"rs are: <br /> Carrier: GI�Erl lccL Policy Nun%ber <br /> I cartify that in time performance of the work for which this WmA is issued,I shall not employ any person in <br /> any manner so s4 to becomm svb*ct to the wvrkws'cornponastion lows of Gedifomis, and agree that if I <br /> should became subject to the workers'cornWsabon provisions of Section 3700 of the Labor Code,1 shall <br /> forthwith oompy with Mose provisions. <br /> Date <br /> Printed Mane: T P-���►-t T <br /> i <br /> WARNING:FAILURE TO SMCURII WORKEM'COMPIDMATION COVERAGE IS UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FMEB uP YO ONE ltuNDRED TMOUS"D DOLLARS <br /> (9100,4 00-� IN AODITWpW TO THE COST OF COMIMMATION,INTERGST,ATTORNL-CS FtffEa,AND DAMAGES AS <br /> PROVIDlD FOR IN SECTION 3706 OF TME LA9OR CODE. <br /> i I• �"' (C47 rce""d aunwited ropresenlhrdre).hereby <br /> to sign 0"San Joaquin County WraM PernNt Applkwtion on my behaW- I undergand Uto suthorimtkm is valid ler <br /> *" t and is IWHvd to ffw wcw pftn dated on 9 Frent~or mita icoart. <br />