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10/03/2001 10 23 2094683433 FIFTH FLUOR F'AbE Ob <br /> + SEP-10-2001 �5'S5 CAMBRIA 1707 935 6649 P 03/Q3 <br /> ioo (i R` ' Refs#: <br /> JOE ADDRESS.--±3 <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby afWrrn that I am 1rcen:ed under t"O PMMOMS of <br /> ch ptefmitome atnr d-7cin g� Seeaon 7000 of Divr3ien <br /> 3 of ma auxrncss and PrOrels6ions CW8 aro M <br /> L�ccnse� 7 1=xpiratran Oate <br /> Oats Contraclzr <br /> 9 <br /> S,gnatum <br /> WORKERS'COMPENSATION DECLARATION <br /> i hereby affirm vnder;)enaity or penury one of the following dec2lamttens' <br /> 1 have and -NI Maintain of Cera%Cffl8 of cort�nt to S0K4nt;ure far wtxke s- mmpensation as prmded for by <br /> Section.3700 of rhe tabor Code, for the performance of the wore Ibrwhch dire permit is issued <br /> 700 Of Ove Law r C*db <br /> forarhe perfo+rma ce! off the wom for which Lh s�m"issn ued- my workers'corr,oer<DuOn inU9W c3mer <br /> P <br /> and porlcy number are: <br /> Carner—alOCfC iYdnLaCPogicy Numbar <br /> D 1 Gemly"L in rale Aeroof+rwice 0q ft wotu Mw which Ors punnet rs issued. I zMa AA OmPlay rYDeComt OWSrJr manner <br /> so as to b6come wbia"to thf�srV aDrrrpermsoan LW-S of Ca►��cc shsf, and 9 t v Lfl&hWd w�h tffine Qfor�s�00 <br /> me wortersf mrnpaflsUkM PrO%Asions of Sea.vn 3700 d lbe aba <br /> Gate App c*M <br /> WARNING FJULURE TO SECURE WORKERS'c0MpENSATtar+ L:oyLRAGrs is L1NlLAWFUL.AND S14AJ.L SUt3JECT <br /> AN EMPLOYER TO CRIMAKAL PEN^L 7le3 ANO C%VIL.FIRES UP To ONLF HUNOAEo THOUSAND DOLLARS <br /> (loe.00e).IN AODr otj To THE COST OF Compe :SA-nON.OAMAGES As pjKoD rtVF-o FOR IN SECTION Xroc OF <br /> THF LADOI4 COOS1N TER&3T,AND ATTaRFtEY'3 '� <br /> 2/2 a6ej 'Pt, sL LO-ve-day `Zoeo PLC SZ6 ` oui 'OUY15al g 6UTTTTJp 668U9 AS luas <br />