Laserfiche WebLink
IGiiL Uy . VI GL)Lr — 111J i IG.JL111Y7 1II4. ) =G. SIU ­­1 ,.)cp-0-aa IV.G`+] I r1LSC G , <br /> SEP-07-99 TUE 10 :69 PN ' nOTHILL ENGINEERING 204 367 1163 P• 03 <br /> JOB ADDRESS: <br /> LICENSED ENSED CONTRACTORS DECLARATION <br /> d under the provisions of Chapter 9 (commencing with Section 7044 of Division <br /> 3 of he Business and Professions Code, and rrty license is ire full force and effect, <br /> I hereby affirm that 1 am fiCense <br /> Expiration Date 3 � <br /> License <br /> Contractor <br /> Date 4LI24� <br /> WORKI=RS' COMPENSATION DECL..ARAT10 <br /> ertificate of consent to self-insure, or a certificate of Workers' 00rrmPens86on <br /> 1 hereby affirm that t have a Certificate <br /> (Sec 38011, Lab.0}, <br /> Insurance, or a certified copy <br /> Company <br /> Exp. Date <br /> Certified copy is hereby furnishedinspection Division <br /> C3 Certified copy is filed with the County Building <br /> CERTIFICATE OF EJCEMPTION FROM WORKERS'COMPENSATION tNSEJRANCE <br /> C -- <br /> dotiars($144) or Less) manner so <br /> feted,if the permd rs tar one hundred Io any person in any <br /> (This section need not be Camp permit is issued,I shall not 8mp Y <br /> I certify that in the Performance of the wa+lt for <br /> ens tion III f Catifomia. <br /> as to become subject to t7ne Work4rs' Cornp <br /> applicant + <br /> patetion.you should DecoR7e subject to hq Workers' 4 <br /> 7O APPUCANT' If.after making this Caortimrcu b°rt�frtEhwi hp comply with such proytaions or this permit ahatt , <br /> NOTICE provisions of the Labor Code,y <br /> Compensation p <br /> be deemed revoked. <br />