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Woe <br /> FROM FR!JNTIER DFILLIhtG FAX NO. 2199 669 0211 Jul . 015 1999 09 : 14AM F1 <br /> f_ GiL IF , G !ZQPHY5j Z+ AL GF' , 209!R274a 10156 P,, 02 <br /> +^ 9 a _ <br /> RE V <br /> R <br /> JUL 0 7 1999 <br /> MENTA] iEALTH <br /> PERMIT / SERVICES;' <br /> JOB1 DDREM 749 E . Charter l6ay7 Stockton , Ca PERMIT#; <br /> LICENSED CONTRACTORS DECLARATION <br /> I <br /> i I hereby affirm; that 1 am hoonsed under the provisions ::f Ctaptar 9 !con nroncir,g wit h Section 700G of Division <br /> i <br /> i 3 of V'e Bus +nFss and Professions Code , and my licenses in full force and ef`sct. <br /> License # Expiration Dai6 G <br /> dim eie, <br /> LIZ$i{InatUYa �_ f <br /> ERS' CO PENSATION DECLARATION <br /> 4 Hereby affirin under pen aity of penury one of th+3 IcIloWing deolaratie s <br /> 1 have and will maintain a certificate of Consent to aslf-insure for Workers compFrsBtiOn, ss providsd fwr by ' <br /> Saction 3100 of tt e Labor Code, for the perrormanc� of the work for WhiCh. awls rei'm is lssuac. <br /> I (}$v@ $! td will rriaintaiti WorKers' comPPnSation ins'arerice, as rewired by BecUon 37t7() of ina LBJOr Cocas <br /> for the performance of the work for which this permit is isgued . My workers' cornponsatioR nsurance carder <br /> gno policy number are; <br /> �.Policy Ncnie-r <br /> i <br /> certify that in the performance u` ;he Yti o'k `cr wh ;h this permit Is issuOd, I shall not employ any person in <br /> any manner so as to necarne 3UbjeCt to who warkcrs' cv' pensation taws of Gallforn a., and agree that If 1 <br /> sYauld become aurajfsot to trio wori:erg' Compensation prOv;slons of Section 370lJ of thy LatIor Cede. I shall i. <br /> foNhwith comply witn those pro+vision. . <br /> ^_aro ;;k ma. 5�F � signature: ' �— <br /> wAKNiNGi FAJLUe TO SECURE WQRKEFs' COMPENSATION COVE GE 1$ UN FUL, AND SHALL SUSSECT <br /> AN EMPLOYER To CR1MI140fd.. PENALTIES AND CIVIL PINES UP TO ONE HUNCP,ED HOUSAND dDLLARZ <br /> (t09;Ovo) , IN ADDITION TO THE CO$T OF COMPENSATION. DA141AGE3 A9 PROVIDED FOR IN SECTION 3704 OF i <br /> TNs LA60R COOle, INTEREST; AND ATTORNEY'$ PEES. <br /> i <br />