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Aug -20-99 OIB:43A VIRONEX, INC. <br />AIJG-70-99 FP, I 09: 18 A'1 <br />5102660963 <br />JOB ADDRESS:I nth �or `> T�feG�- PERMiTk <br />LICENSED CONTRACTORS DECLARATION <br />P. 03 <br />r <br />I twiroby affirm that I am 6consad urxier the provistont of Chapter p (commencing with smbon 7000 of Division <br />j3 of the Rusiness and Professions Code, and my Manse is in full tone and effect <br />L,oerne '1 0 5 `'1 f' Expiration Dale <br />i flare _ . iC l% i 1 Contrimctor <br />Siprtatune <br />WORKERS' COMIPENZATION DECLARATION <br />I hereby affirm under penalty of Perpry one of the Ulowing declarations. - <br />i have and wilt maintain a certificate of Consent to self -insure for workers' compensation, as provroed for by <br />Section 3700 of the Labor Code, for the parforn>arx a of the work for which this permil I$ issued. <br />I have and will ma,ntn,n workers' cernpensatipn ins►irgrrce, as required by Section 3700 of the Labor Code. <br />j for the perforrnance of the work for which this permil Is is:uad. My workerscompensation tnsurance Carrier <br />j and policy number are: <br />Camey i i 1 (� 1 C.. L ` . C. SYl'� Policy Number fU LU is c <br />I certify that in the pertonnance of the work for which this permn rs issued. I shalt not employ any person in <br />any manrwr co as to become sub►ea to the workers* compenaahon laws of California and agree that if <br />should become subject to the workers' comperw=ion provisions of SeCUgn 3700 Of the Labor Code, 1 shall <br />inRhwilh comply with those provaions_ <br />t <br />o-aae.(JJ<J`— <br />Cil <br />WARNING- FAILURE TO SECURE WORKERS' COMPENSAMON COVERAGE 15 UNLAWFUL, AND SHALL SU&Wr-T <br />AN EMKOY ER TO CRUNAL PENALTIES AND CML FINES UP TO ONE RUMORED THOi1SAND DOLLARS <br />OMWO). ADDITION TO THE CO*T of oOMPENSAT10N, DAMAGES AS PROVIDED FOR IN sECT10N 37DC OF <br />THE LABOR CODE, INTERTEST, AND ATTORhyrs FEES. <br />t , <br />w <br />r„r <br />V.41 woad w,s = 2 i 666 t -B 1 -G <br />P.02 <br />