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NOV. 17. 2000 3- 50PM ERM SACRAMENTO NO. 610 P. 3 <br /> �i�ivu - !1. L'��1�• 1:73I����"CI(lvl SHIYICiVI� ^, �, ... . .,..., .Vu. CJ: r. � <br /> J <br /> -r�'"f'San;JoBgtalhCouoRyEnvii�enen�+talKwltlt9tenrijoas;,'Uh a�:Pi+relti>:•�p�t[1F�tie�'��ppie��t - <br /> JOMAbCllkffiS: Mc LAN� <br /> r, - i . • , •� it N. •� _ �••. <br /> LICENSED CONTRACTORS DECLARATION (LO <br /> I h.reby affm that I am Iloenaed undw fig provwons of chapter 9(oorrmmenoing with Sedion 7000)of Dnision <br /> .3 of the Business and Profesalans Codd and my Ilesnse is in full force and eNeM <br /> I.iconse FxpL-&an Data: 3/ <br /> NtD: /d/"7o 0 Ceritracttor: ���-�r' /7 -- /'/'1/Q-=- <br /> Signaturo: YJlrto: 1�(¢yG� <br /> Printed ft;rr�IC: .� <br /> WORKEIM COMPENSATION DECLARATION <br /> I hereby e,rm under penalty of perjury one 0f tre foliQvAM daolerJtbrlg: (CHECK ALL THAT APPLY) <br /> l have and win maintair,a'cerlifiow efeanwtto"If-Insure for workers'= mpensation,as provided for by <br /> Secton 3700 of tt,e Labor code.for fie perC t ow-warkforwhirr this permit is iaaved. <br /> Y.—Move and will maintain wo*am'compenssGon"urenee,as inquired by Section 3?00 offt L&CX Cade. <br /> for fie peff maree,of bw work Far which this permit is ivsued. My wgrkers"aompeMS01on insls"ce <br /> carrion v%d policy numbers ar$:- <br /> C�Ki(�l-; Policy Number: �� <br /> I cwffy that in the perfofrnaMe ofiMe work forwhich this penrA ie issued, I shall trot errr1310y any Persom in <br /> arty manr4r so u tb ta000rne subject to the workers'compwitr CA laws of Galifomia, and agnss t4at if 1 <br /> should became subject to the wrkeM'c0MP9A0a1len previsl0M of Section 3760 of the Labor Code; I shall <br /> forthw�M Complywith moose pmvvislars . <br /> Oats ( c D o .SieriatW►c: <br /> printed Name: 04A-rLK <br /> WARMNG:FAILURE TO BECURE WOR AM,00UPS leatt0N COVER=fe UNLAWFUL AND SMALL SUBJIMT <br /> /W)WRYER 16C MI1KAL PMA16TM AND CMI.F1N 5 UP T9 ONr-NtiNDRM TMLIiiAND 11011JLAM <br /> (i100Aa0 IN eleldn nom TO TNIE cm op=rkmAT*K INTER y,ArmRNErs Iaaf ARID DAMArau As <br /> i RMWED VCR IN SECMN•3?o5 CF THN LAMR COOL i <br /> ' 1 <br /> (stenatvmofr O llsirtsed*Uthorfsztd rspraffww�Mye), <br /> hereby authmm(Print nanttQ <br /> to sign this gft Joaquin C wmty Wart PtrmrtAppticatian an my aerj f, i undentind this a►ivoobmdon is volld Tor <br /> ons(1)year and>s Awam to the wwk plan dated on the front page of Oils vWtwion. <br /> r <br /> Pbs*lf Fax Note 7671 bate 1// Paces <br /> Tb From <br /> CoJQepG Go, <br /> Phone X PFtone a <br /> Fax 0 Fax>k <br /> T <br />