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NOV-03-1999 17:30 CAMBRIA INC. 1707 935 6649 P.02/02 <br /> 'Li gyral <br /> p D <br /> I JOBAppRE55: Z`fS E• (-✓e � "PERMIT SRO: <br /> I <br /> LICENSED CONTRACTORS DECLARATION f4CD) <br /> I hereby otlirtrf that I am licensed under the provisions of Chapter 9(commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code)and my license Is in full force and effect. <br /> License 4A%165 ExplredonDate: January 31,9202-_._ <br /> ` Date: —LI Y 4 Contractor CREGG <br /> signature: ;��7% J _ _n Tine:�$�RATT Ns aNAr.Fu <br /> Printed name: <br /> i <br /> WORKERS' COMPENSATION DECLARATION <br /> i hereby affirm under penalty Ot perjury(11100f the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a Cettlhdte of Consent to self-insure for workers' compensation, as provided for by <br /> Satllon 3700 of the Labor Code,for the performance of the wont for which this permit is Issued. <br /> I have and wig maintain workers' compensation Insurance, as required by Section 3700 at the Labor Code, <br /> for the pertormenoe of the work for which this permit is issued. My workers' componsatien insurance <br /> carrier and pONCy numbery ars <br /> /Genteri)11L RROON OF ORANGE (Wiry Number:• t^a o a <br /> J I car"that in the performance of the work for which this permit is issued. I shall not employ any person in <br /> any manner iso as to become subject to the workersCompensation laws of CHNfornia, and agree that If I <br /> should became subject to the wofluxs'compensation provisions of Section 3700 of the Labor Code, I Shap <br /> forthwith comply with those provisions. <br /> onto:Y / X45 .Signature: <br /> 1 Printed Rome•. CHRISTOPHER PRUNER <br /> WAR*RiG*.FAILURE To atCURra AN EEVPPCWlt TO CRIMINAL PONALTIES AND CSUBJECT <br /> ML FINES UP O ONE HUNDRED THOUSAND DOLLARS <br /> LL <br /> P(iijoill,lifti,IN IOW To HE OF TOF HE I. A90RENSAT ON.INTEREST,ATTORNEY'S PEES,AND OMMAGES AS <br /> PROND[DOR <br /> 11, r!r _ (G57 license holder).hereby <br /> G�lbel S (Consulting),to sign this San <br /> Joaquin County,well Ps rnit Application on my Behalf. I Understand this.uthorintlon is valid for one(1)year <br /> iii-dip,IM1ard io the were pian doled on the front page of this appilwdon• <br /> TOTHL P.02 <br />