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v <br /> c�P o A <br /> Sun Jo grf+e County Evvim mental F tGM t]opaftnmg unit N Wrtf Purmit:ApptiraGo/n�Supplanuk"t <br /> JOIDADDRESS- <br /> LICENSED CoNrMACTOR$OECLARATIOPIL( CD) <br /> I,horeby affirm W l*M Mc'WMW undo tt+a PY06SiO05 of Cra"t Q(=MMQntk'g Wtt Sachan 10W)of DIViS$Dn1 <br /> 3 of ttre Dusinws snd Prdk**=Coat and my its In*0 tort*W4 e*a <br /> L�cenSe Q D*afic^QTte: <br /> Dow i Z-{2r. l o <br /> n , <br /> Waled nom; <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby Ntftrm un&r pm*ty of pa4"OW Of thn'foltcNviry dudwaWft (CHECK ONE) <br /> 1 have and vAR nwint min a aorfirtc*x of conW4 to sett ins m for wmf(w 'uunpen 05M on provided for <br /> by Section 3706 Of du L*w Code,for the p&Wmlv*4f the work for which 244#xt+A is issued. <br /> I have and will main*jn vwwom,c m7rm=von msu wm.as mgWmW by Section 3700 of Me Labor COW. <br /> for the perkaww co Ot tlfe.ma*far whit h tris pem9t 19 lamadL Iftw rkeW eOmPerrsstton"muranoe <br /> c mimf and policy nur bora are. <br /> I certify that in the peffOmrancs Of the work for whicb tinct permit is issued.l stroll and en-ooy any Pemm in <br /> any manner se os to become subject m the wOrkans'wrgptn33ftn laws Of C2tllorth8-W4 23reo anal If' <br /> should oaoxft ssr4EO t0:he warkexs compenraban prvvWorrs of SeOM 3700 Of ft tabor COW,I SNOB <br /> ,brf mit cm"%vhh those I)MIMOM — <br /> Expfrallon Mae; 1. igrwwm: )S—=� <br /> ptfntaet 9faue: <br /> WA1ft11 NO.-rAHAW TO SMPZ WAKW CONATION C E is UNUIWKII.,AMID SHALL SPJk*6T <br /> AN ENWVNM TD CW1141MAI-pE W% -nE3 A11D GanL nNes tip Yo OW HUNDRED TI40LisAIW Dota-ARS <br /> (S400,00U 94 ADDITION TO TW COST OF .►ATM tit M"&T.A fiY`3 rEM AKV AAUAAfs`U AS <br /> PF4CMD D FOR IN sECftOM 1709 c,f THE 1 AMM 0006. <br /> AUTHOFtIxATION rOR OTHER THAN C-7 SIGNING PERMS APPUCA-11ON <br /> :tOnaawe ofC-7 pt: ma authorized m7wm wAaVw)j <br /> u�e„aun►ofe�etf�� �w+rF•et- <br /> tv sign this San Joaquin CawV WcA Penult AoRea&m on my b1W. 1 wnd.rtt kna ur no mvO oritallan W valla for <br /> am f,)yaw end it flrn ftd t D Vw work FmR 42WO on the icor*Fxgs of tb appOeallm <br /> 6MID4 <br />