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NOV-03-1999 17:30 CAMBRIA INC. <br />k <br />1707 935 6649 P.02i02 <br />JOB ADDRESS: z' 'S' �. ,e'4:x� ERMIT SR#: 02-42s4 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am lioansed under the 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 />License: Expiration Date: January <br />Date: _�..�- S S Contractor. <br />Signature, Title: ()PERATTONS M,814AGF-1 _ <br />Printed name: CHRTSTOPIIER PRIM <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations. (CHECK ALL THAT APPLY) <br />_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />Seedw 3700 of the Labor Code. for the performance of the worts for which this permit is Issued. <br />I have and will rnslntain workers' compensation Insurance, as required by Section 3700 of the Labor Code, <br />for the ;== of the work for which this permit is issued. My workers' compensation insurance <br />carrier and poticy numberl are: <br />Cenlslr.wiN 5 cORRQON OF ORANGE ( 15otley Numbar:a Al 1 ^AA'te <br />J I cenIN that in the perbomtance or the work for which this permit is issued. 1 &hall not employ any person In <br />any manner oro as to becOM0 subject to the workers' compensation laws of California, and agree that If I <br />should became subject to the workers' compensation provisions of Sectlan 3700 of the Labor Code, I shall <br />forewAth comply with those provisions. <br />Onto: ! f< 4 r Slgnaturo. <br />Printed Name: CHRISTOPHER PRUNER <br />WARIMO: FAILURE TO NZGUR` WORKERS' COMPENSATION COVERAOR IS U?41—^ YPUL. AND SHALL SUBJECT <br />wan EM'LWalt TO CRIMPtAL PUNALTW3 AND COAL FINES UP TO ONE FtUNDREO THOUSAND DOLLARS <br />(Sio0,9M), Ili AW"JON TO TME COST OF coMPENSATION. INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PRtWMD 1x011 IM MIECTMU 3704 OF THE LABOR CODE. <br />(C•57 license hotdtq. hereby <br />Grv?b✓l C (consulting), to sign this San <br />Joaquin County welt Permit Appllcatlen an my behalf. I undernbnd this authorizet;on Is valid for one (1) year <br />and Is Radard to the w uta plan doWd on the front Pape Of this appllceeion. <br />TOTAL P.02 <br />