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JUL-31--2001 08:39 CAMBR I A INC. 170'7 935 6649 P 02/02 <br /> J � <br /> .JOB ADDRESS: ` -1DO M0V-CjZLn& (!0t0+j 5��PERMIT#. 0027 03 I <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm mat 1 am licensed under the pnwislons of Chapter 9(commencing with Section 7000 of Dlvrtron <br /> 3 of the Business and Professions Cooe and my kense ,s in fent force and effect <br /> License# F-xPrr2tron 0 a Q1,/A1/A2-,X _ <br /> r <br /> Oats CorlUvwzr r�' ,i Zjz <br /> signature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under Penalty of per}ury one of the following ddcalaradonsr <br /> Nave and well maintEdn a ceruffc ate of consent to self4nsuntt for workers'compensedon as provided for by <br /> ection 3700 of the Labor Code,far flee perfomnance of the wort for which hes pelmlt fs Iaaued. <br /> have and will n%srnunn workem'compensation Insurance. as regwred by Section 3700 of the labor Code <br /> for the performance of the work for which this permit IS issued ftilly workers'00m ensa ion insurance carrier <br /> and Policy number are_ <br /> Ir e <br /> . Carner a <br /> Pofxy Number_W,6 7-1 rC711;S6D <br /> i © t cen,fy that in the perirxrlranc&of thib wom for whch ttrs perrfnt fs;seVed.I shall riot emptay any fluor+in any manner <br /> so as to DOWme subject to the wor kenr ewpensanon laws*f CelhOfnla,aAd nr"that W,shwd aoawne subjw to <br /> the workers cornpen3aucrl provisions of Seclbn 3700 of the abor Co I ahaU f rthmnth orarmlyt weth thee*pra,ns,ons <br /> Date Applbc-" <br /> WARNING-FAILURE TO SECURE WORKr;RS'COMPSNUTIOm COVERAGE IS (1NLAWFUL.AND SKALL Silt3.1ECT <br /> AN eMPLOYeR TO CRIIeINAL,PENALTIES AND CtVtt.FINES tJP TO ONE HUNDRED THptjSAND DOLLA" <br /> {100,000). IN A0OITI0H TO THE COST OF COMPENSATION. DAMAOIES AS PROVIDED FOR IN SECTI4#j1706 OP <br /> THE LAaQR COM INTEREST.AND ATTORMY'S FEG9 <br /> I <br /> I I <br /> � I <br /> I I I <br /> I I I I <br /> Z/Z a5ed I to 0t1`V0-kL6 Thr I I `ZOEO eLe �j!6 ` oui '16uz1Saj V 6utTTTJa 66aug Aq juas <br /> I II I <br />