Laserfiche WebLink
10-0/03/2001 10 23 2094583433 FIFTH FLOOR PAGE 03 <br /> SEP-28-20121 10 50 CAM?RIA 1?0? 935 G649 P.02/02 <br /> • <br /> JOB ADDRESS: �°? t00k- <br /> PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby atlirm that 1 am licensed under Ute plovisrons of Chapter 9 (comr0mlan4 wdh Secrron 7WO of Dnrrslon <br /> 3 of the austness ani Professtoiq§Com. and my ilcense Is in iutit force and affect <br /> License 3 C.r.L 7 Expiration Daae <br /> �f <br /> Dare DiY`ll���T T�Jf <br /> g1j��lL�_L ContrdC�r zJ <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 Hereby afl;rm under penalty of penury one of the following dec-zlaradons <br /> have and~rill malrttan a ceru%=ate of censent to self4nsure for walkers' compensation as provided for by <br /> Secttan 3700 of`he Labor Code, for tate perfbmence of the work for which this permit Is Issued <br /> 1 have and will maintain workers' cor-lparifratlon Insurance as roqulred by Section 3700 of the Labor Code. <br /> For the pttrrormanpe of the work ror which Ihts permd 6 tssucd MY wor-kem'pornoonsat)on,nsurancc car^» <br /> • and policy number are. �+ <br /> Carney fact d Palley Number wel � CL O <br /> ❑ I Cp"that+n the pedoirrparv--a M irie work Ior%vhreh M4 permit is Usued 1 shah riot ur^Plw any Pfem*++n srry rrraru'+ee <br /> I so as W oecome subbed In Me werkers ca.n9ens400n laws of Caftifomla and agree mat it I should become suolect la <br /> the workers cDrnpensaton pmvracutis of Section 3700 of the-3b4ir Co 1 shall Xf )�,Allkl COMDly With u'+oac 9rov+SlonS <br /> Gate <br /> Zeal 0 Applicant <br /> WARNING_FAILURE TO SECuRr&W0RKEIES'COMPeX5AT10N CONERAGC IS UNLAWFUL.AND SHALL SUaJECT <br /> AN EMPLOYER YO CRINIINAL PENALTIES AND CML FINES tJP TO ONE HUNDRED THOUSAND 00111lARS <br /> (1 a0 000) IN AODI-ION TO THE COST OF COMPENSATIOK DAMAGES AS p110v1DED FOR IN 3EC•rION 7706 OF <br /> THE LABOR COML INTEEtF.S7, AND ATTORNEY'S FMS <br /> 4 <br /> AQ7 : 7T Til—R7-d01:; <br />