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Jars 27 03 02: S9p Wadr- Woodward 1 -707-'474-5677 p. 2 <br /> alp r�xsarst 14.11 209-57 '25 MODE'STO ATC <br /> -toy-1995 10; 1 1,1 M F��/ � PAGE 02 <br /> !, R.G <br /> I $aN�gY1n • <br /> ++1ntr tAywmmenlal Noeleh serviioe5,Mit IV w10 pit^Doit:nflion lwppt6nwrl,t � <br /> JOB ADDRESS• 162 <br /> •.��., S, r '^ PERMIT $Rai: L rL <br /> LICENSED CONTRACTORS DECLARATION <br /> i <br /> 3 eyB a Pry C dt ^m+vY ltcennssoef iChapbar 9(cr * n�with 7000)of llvrsrCnPOO <br /> s <br /> In evil Force end efifect. <br /> Liren5e t_ 7/(gyp �1� <br /> EVirsLan Date. .• <br /> Oato: Coswtracror <br /> 8►ar�tnrta: 77tFs:_ _ `�r� ffG <br /> PrintW nal"; 1 <br /> WORKEW 001AFElI"TION DECLARATION <br /> thereby ailfirrn under pertafty of fwINrY one of me fonowint Clecfaratbns: (CHECK ALL THAT APPLY) <br /> t have and MR maintain a C'srVftMt@ Of CCHMf t b0 6611 insure for workers,rnmpersaall#kln, es provided for by <br /> Simon 370D Of the tabor Code.for the <br /> yeri+orrrlanOe of the work fpr Whch this perrrtlt if Isisrad. <br /> !have and VAN m anttrn wo**rs'compenssaaon koww ca.as required by S n 37{50 O the taencebor Cafe. <br /> I for the�of the work for which Tn*.9P "is k4ued. W w d%r6'Cortrpensation irtwr <br /> carrier and polky numbers art <br /> Carrier: U <br /> ftky Number. i <br /> I MARY mat In the performanott Of the work for which this parrnit is issrte�,t>!�Y not airy inannw so as to become wbj ernp}oy any pe,^sor rn <br /> shoulQ lace to t7rt workers'C8n1ptrt6atian Paws of Cahfomia,anC agree triii it I <br /> becDmC subject to the workm'corrpensatinn t� WOns of 56Gtivn 3700 of;rte 4aiwr CatlE. I it I ' <br /> !orth comply with lhpge 9rVV Mr1 <br /> Date_ X07 <br /> Signature: <br /> PrilM1ted Name: klid .� <br /> WARNu1G-FAILURE TO SMuwE WORKERS'COMPENtC^004 COvVitc.GE I$UrtLAWF$jL.AND$HALL Stf6 EC7 <br /> AN EIYIPLOYER TO t;t�aAfNAt vEr�►LTtE$AND CIVIL FINES UP TO ONE HUNDRED THOUSANt!OOLLARS <br /> ClS1bO,CeD.1, IN A001710"TO TME COST OF COMPENSATION,["REST.AT'T ORNEY's A5 FEES.Atr0 DAMAGES <br /> O*O"Dea frau of SE`TTON 37%OF Tats=LABOR CMW- <br /> (CS'IrGertaea ar:lnCr;iec rcp+esens�tvo?.�+eroDy <br /> avthorixe� / <br /> to sign th's San Josquir,County" Wn PQrrnit APPlicnion an My behalf. r unde+stend"tris authotizallon IS vaiid Fpr <br /> one t1} tar and is riTnited is the wnrle n dated on the}� Ot�yf>pAEgteOh. � <br />