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Aug-03-99 04 : 10P West F' -nat Ori l l ing Corp 916-6? 13613 P _03 <br /> ..., ..o ..o- ra i na • iYd ay.a. ini.� VAAL.i!v WjuIlz <br /> JOB ADDRESS: Z e • �/� PERMIT* <br /> LICENSED CONTRACTORS DECLARATION <br /> 1 hereby affirm that I arr licensed unser the provisions of Chapter 9 (commenCin9 w!th Section 7000 of Divlslon <br /> 3 of the Businass and Professions Code and my license is in full force and effect <br /> License#j Y7 555 27 1 Expiration Dat!--ZL— — � C1 <br /> Date ` Contractor C-S I M U 14 n <br /> Signature ._ <br /> ORKERS' COMPENSATION DECLARATION ••JJJ <br /> f hereoy amrm under penalty of perjury one of the following declarations <br /> I have and will maintain a Certificate of consent to self-Insure for wor><vrs compensation, as provided For by <br /> Section 3700 of the Labor Code. for the performance of the work for which this permit IS Ssued. <br /> i have and will maintain workers' compensation insurance, as reQUIfed by Section 3700 of the Labor Code <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance carne► <br /> and policy number are. <br /> Cerner` �rJ Policy Number tl�) 1�/ <br /> ` <br /> I Certify that In the performance of the work for which this permit is issued. t shall not employ any per yon in <br /> any manner so 213 to become Subject to the workers compensation jawn of C rnia. and agree that if I <br /> Should bec©rne subject to the workers'compensation provisions ch b of the Labor Code. I shall <br /> folthwlth complygwim those provisions. <br /> Date`O ' 3 l Signature: V{rot C�t yet c, v1 <br /> WARNING: rAILUR!TO SECURF_WORKERS'COMPI[NSATION COVER E IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL,FINES UP TO ONF"UNORED THOUSAND DOLLARS <br /> (100.000),IN ADDITION TO TWE COST OF COWPFNSATION. DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> LTHE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. <br /> am__.-_._.... <br />