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05/04/2006 THU 08:59 FAX Z002 <br /> Litti.t iV WF -.Il perinit F pp!ir:a,Yiuf1 ::A111p6`mL' t <br /> Sari JoaQuif?Ou:ingy�nl iCOP,lstlr'c o✓.. E~ I � i <br /> ass: _T,� y -s qJ013 ���.�Q <br /> �� Aof�R G —Y, <br /> LICENSED CONTRACTORS DECLARATiON <br /> I hcreby affirm that I am iiccnsed under the provisioi7s u Chapter 9(commEncing with Section 70�C�)of Uivislon <br /> 3 of the Busiiie5s and Ptofessi ns Code and my license is in full fc"-�a an lid- , <br /> ' }� ion[site; <br /> License v' "_-t= A"M <br /> Contra r. *y ` <br /> Me'- —_ — <br /> Y � <br /> Prinfed name: — <br /> WORKERS' COIViPENSATI DECLARATION <br /> 1 hemby af-firm Und- F,enalty of perjury one of the folIDWiliq declarations: (CHECK ONE) <br /> I have and will maintain a cc rtificatr of consent tc,:elf-insrire for workers'carnpensatian,as ProvidoG `o�' <br /> by Section 3700 of the Labor COdE.L for the pe'rfolr�anc-of th?work forwhicii this pr mit is issued. <br /> 0 ofthe <br /> I have and will rnainfa+n W rk iQ which tl � pe muril is is^ued f MYrwe Pr i-ed by �compenction sa(ion insurance. <br /> for the.peifom,ance of tl <br /> can'Iar aNE`C)y num s are: j �!,/r7r/,►, (�� L �/}T5 <br /> Patlry Number: ✓�1 (J C!l�UCarrier. -+ — <br /> I certify that irr,the:perfolmaricz of tt,e work for which this pen-nit iF,N ued,t shall nut employ any pef::on in <br /> arty manner eo as'to hemme subjecA to the wottser,'componsation laws of Galitotnia, and agree that 1fi <br /> should become'% ` the warmers'rampet7sa ion Rrovisions of Section$700 of ti,e Labor Code, (shalE <br /> forthwitl Cum`lywith those piovisiom, A <br /> 1. _ <br /> Date:_ <br /> Sig nature <br /> : <br /> Printca:i Names: — — <br /> D SHALL <br /> 'WARNING:FAILURE TO SECURE WORKC AND CIVIL. NS F SlON <br /> UP To ON'AH J(10 Efl HOU4kND ULLARSo CC e <br /> AN EMPLOYER IN TO ADDICRIMTION <br /> PEItiAl;T O <br /> ($4Ua,b00.),IN gtaDlTION TQ l'HE CQ�T of COMPENSATION,iNl'E€tEsl',ATTORNEY'S EEO,AND D.4Wli4G'E$n5 <br /> PROVIDED FOR iN SC01-ION 37oG of Till`LA50P CODS. <br /> C1�ig1F i YtG. Ql G� l T"AN C-•57 SIGNING PEWIT APPLICATION <br /> (_,ignaturq am-57 licensed authorized ri,Erg�ent ti4r+), <br /> hsrrby vujfj rnzv(p;,Inf naniul ti �.� —. �^ --.-. �— --.• _ — <br /> t i�P:+i�1�l;,Ii.u;I'_yb•.,i:' ::i+o+fie+ <br /> y !Esc t'n,iS A 9oc�'(cl ii ail r'ily l-uhaL', ilnClasK col <br /> tr,niLri @him Scot Jcoagi:9:Y f'o!!.E} VlFll t p� <br /> (ti)v- <br /> r' gur Fi2 1 1;YS6itF%u Cp 1}IF•.a:f CP, d�'r;�C,-Yt1Cl<:r. !.i 'r..,u_is sr <br /> In.,µ <br />