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4A <br /> F.4 <br /> be <br /> 6--18--1999 2-46PM FF40M - p_ 1 <br /> i <br /> JOB ADDRESS: '2201 N WtA :L2414 _ <br /> LICENSED CONTRACTOR DECLARATION <br /> ION <br /> 1 hereby affirm that i am 5oansiod under the pravislans of Chap $(commencing wfth Section 7000 of Division <br /> 3 of the Butt m and Pmftssions Code,and my dkmve is in firl i form and eifac <br /> License 0 ��� l Expiratbr,Date !� h v 95 <br /> D11 1* I z 004 �� �. CCM d1AW4jC �r <br /> Signature <br /> iV IDAKEW CMIENSATi N DECLARATION <br /> 1 hereby affirm under pene4y of mdury one of ate fa4owing do0a aradons: <br /> ,• 0 i hove and wI11 melrltain a ce. rd6cste of mosent to seh4nsurs f r wadisl w compensafti,as for by <br /> Secdon 3700 of the Labor Coda,for Cita perforin of rk for which this permit is i;�ta0d, <br /> 01 have and will maintain wQrMiro'compensaifon ira rarce,sae required by SaMn 3700-of the 1;.abor Code, <br /> for the pelftrmance'of tie want for which this permit is isswW My x onWrW oompensabo 1 in erKe carrier <br /> and policy nuMbow are= <br /> Carrier Ji' fe , dim ero[ Policy Nu er 131. 7 of 74 —98 <br /> U:f cerfty that in the perWmence of tfre wotrk fw wtrbcch lirls peraA is is ued,l OW not empft aw inn in any nmmw <br /> so as to b*varrw subjec:t po ft workAry cotmewatirin bm of cafifornia.and agree Waif]amuld bmme mutat to <br /> Vie workery ovrrrpenwtion prvvimbns a€Sedon 37W of ftie LabigrC ado.I sWifordwAth ONOYTOdww provisions. <br /> oats 21+ 0—w^t 99 Applirmuat n <br /> WARrNING.FAtt_LiRE TO SF-GURE'V1r0WO;?s'COMPENSAMON'C RAGE 13 VNLALrt.ARID"LLL SUBJECT <br /> AN EMPLOYER TO CIZINUNAL PERALTtF$AND[Tito,FINES UP TO ORE HUNDRED THOUSAND D17f.LARS <br /> 4100,00).ltd ADOMOtN rO THE CAST QE COtdPEtJ"110t4 DAMA40Z AS P1DYIUM POpt lit SEC710H 3706 OF <br /> THE LABOR CODE,1NFEREST,AND ArMRNEr$KEEri, <br /> ftst4v Fax NucFWWA <br /> � f <br /> ca. <br /> cajun <br /> e <br /> Pry S <br /> frr +u— <br /> Ibex.4.e ._s. - -- - - <br />