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i � 3- 17-20d 3 : d9PM FROM P - 2 Sen'! I3'y : Hairijye EnvirmunP, ntal.;; 916 354 1786 , Mar - 17 5 : a7PM ; Paye 2 / 2 i ibB. F1DDRES3: : 134 N : 41uM'Tem. St. t Stoch70M PERMITS: LICENSED CONTRACTORS DECLARATION I treraby affirm that I am licensed under the provisions, of Chapter 9 (comMoncinq with Section F600 of Division 3 of the Business and professions Code, and my license is In full force and effect. Llcenserf S n � Expiration pate oats �_:� J/� _ Contractor f 13GN EWvJ ?iy 4MFWT.Aa, _ Signature sy WORKERS' COMPENSATION DECLARATION I .hereby affifin under penalty of periltry one al Uto following decaiaralmns: I�I Q, I. have and will maintain a cerlificate of consent to sep;lnsure for workers' compensation, as ov+ded mor by Section 3760 of the Labor Code, for the performance 'of the work for which this permit is ass d. 01 have and will maintain workers' compensation .insurance, as required.by Section 3700 of tht tabor Code, For the .performance offhe work for which this permit is issued My workers' compensation insurance carrier and pocky number are: l Carrier ,` "Yu, D P6110Y Number (')L) d 1 certifythat in the perfomaance of IM work for which two permit is issued, l shag not employ. any pe In any manner w as Io become subiecl to Uie workers' comperrsadon•bws of:Cagtorale, and rpreaNist if 1 shoulE b 40 no% Wbiactio the workers' componsallon provisions of Seclion.3700,of the Labor Code, .I shaiffodhwith comply with 11 mm provislons. Date 33 If7 't Applicant V WARNING. FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL, AND ALL SUOJECT AN EMPLOYER TO CRIMINAL pBNALTIES AfW'CIVILPINE$ UP TOONE KUNDRED TCA NOUSAND� RS (100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED' FOR IN SEC ION 3706 OF THE. LABm CODE, INTEREST, AND ATTORNEY'S FEES. I � I i i I