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1�•e.r rIY LrK N�ItitVILLE 916 786 0366 TO 9-12094683433 P-02/08 <br /> JOB ADORESS: <br /> :PERMIT#: <br /> LICENSED COti T RACTORS DECLARATION <br /> I hereby affirm Ulol I an'Ikenyed under;,ye pravlsions of Chapter g(Commencing wllh SeGion 700 <br /> 3 of the Business and Professions Code,and my IlOens f C In full force and effect. <br /> CC U of Urviswn <br /> lleense# u� ,�.�l0 g <br /> Expiration pets -30—Zoo f <br /> Dale <br /> Sign' use <br /> KERS'COMPENSATION DECLARATION <br /> I hereby sftirm under penalty cf pc1•1 u Vr1Q Of the folk7th 1 7 9 d ecalarapona: <br /> O I have and will maintain a certificate of consent to selFinaure for workers•oompensatwn ore ruv <br /> Section 3700 Of the Labor Code,for the rromtos lel of the work for erywtoc IIS <br /> � p idea for U� <br /> O 1 have and will maintain perm!is Issued. + <br /> ror tha workers, the <br /> insurarrca, as required by Section 3700 ul the Labor Code. JI <br /> Aarforrnance re the work for which this permit Is issued. My worker&•compensalion insurance�,ef <br /> and policy number are: <br /> Carrier 7-7 � a <br /> Pulit:y Number 5�1 wce-k- i <br /> O 1 testify that in un perlomwnoe Or II)e w,Kk•w <br /> So as to bvcvnss&ub)IM to IM workers'Corr>p y tMs Perrnrl is issued,1 Shall not-opley■r <br /> the waken,oomponsa(,on provisions of Sedlon J 00 0l Us �CMIkxrUe,and apraa&hal!/I alsoWpe�L any Nrsn►ser <br /> Cebor CW0,r d bacon»suDlea to <br /> Date si►aa r lh campy wilts sho=e Prvvlcloaa <br /> Applicant <br /> WARNING:FAILURE Tp <br /> AN gECvriE YlrOfietEiiS,COk1pENtiATION C <br /> EMPLOM TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUMORED THOUSAND DOLLARS <br /> (100THC,000).IN ADDITION TO THE COSY OF COMPEMeATION,DAMAGES^ PROVIDED ORSECTION <br /> VIDN a13 UNLAVWUL,AND SHALL sp SUBJECT <br /> LApOR CODE,INTEREST,AND ATTUR118rS FEES. <br /> t►Ut <br /> ������awr..s-oaf•-.s <br /> .ry <br /> '"r'.7y,1ti rw.tllwlw <br /> Jbn 144"Older Speerrwr.E■Norouen,brc <br /> tirA.4w. ?SGS W-C.len thi•e <br /> tic.•.'ilz7ti6 slnrkly., CA <br /> 9!QQ!. <br /> 201.465.8712 qa <br /> .)1)9 405 Q1(i I�. <br /> 2Uy.993, r <br /> i <br /> RUG 13 '99 10:24 2094658773 PAGE.02 <br />