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ioiaiizooa TUE oa:aa FAX 2002 <br /> ���✓fig �� <br /> _ )']rit..lt1O(1 5::�1ilE5rlldnl <br /> .Inaquin Goun±y Envimnmvnts Ei_�I[E? a-,Art mart <br /> San Unit lV tti'ell Permit AI r od�� � <br /> ERIViIT 5•R e: <br /> - /CPNi� �- ��-i_ of <br /> J-1CF vSED CONTRACTOR OR DE,GLAP.FiT(O � <br /> that I am lixn(:� un <br /> 1 he,ehyder 411e pr,Svia!ons of(%1?apter a p amore lciug w!th :;cc F <br /> Yn (:Udo. <br /> 7000j ni C%ivision <br /> ns(:Udo.and tnY Itcenfie E,in full fal'ce a1x1. <br /> g Of the Business and Arotessi a — <br /> Licensa <br /> Co <br /> phiated..13 FRI <br /> W13RKEr2S <br /> ' CORCPEN�MCE ARATION <br /> f Irn�by atfim?udder pcn 31ty of nerluty ono of filo tc,flowing d tiixratians; (Ci!! ,CK ONE) <br /> I trivia ani will mail?tain a ceriiticete of consonI t°self-insure forworkers'aarrtpensaiion,a::piuvrded f4; <br /> [,y Sec1i°n 3F-00 of;he I..i',OVG0de, for[hr.: ptrfomranu':°f tttr:W°fk farwf,ic 1 tHis prJmit is Es�ued <br /> 00 Of <br /> 1 nave,and will rnainta�work crxnprnsa[ion in�urence,as requ'tfed by Section 3n.-AtiionnsurahCc, <br /> for the periomrrr x°f�?e.woftr for whldl t s.pp mit is is.uec3. MY vod nes' ,,MNMC <br /> Ceffiar M.;fx7r1(.y nura ,am: oat 'O� _ c7 . <br /> [ '� — <br /> policy NUnlSer: pc- <br /> carrier <br /> i cr:tlfy ttCitin thn pertomtanc�of the wa.rk for W 11irh Ihis,perrrt!t is lc,ued,t shall.noi en?PY1y any persurl in <br /> {my rxgtlper s°as to lxxo0?s subject to itte workers' romPzttsaG°rt 1 1wa°f 3700 of th and of C that iC <br /> :should became'-tkler;to the compem;u °nPrO^sions of^xc1 700 ai filo Loh 1r Cade, 1 shall <br /> fi,rthw!th Cornply+rnth those provisions. <br /> signature: <br /> Date:__,_ — } C )nLi'�.• <br /> -E:IS IjNLAWT7UL,AVID <br /> SHALL <br /> AP!EpAPI OYER TO CkIMSNRL <br /> PiROV�uPsirFPfirrltEGGitg1i37E06NfALI?EHrALfN<5D UG'iIco�Q[?TIlCoNU, IPNTTFO.ROEHST,1iACllN7D[)RFteNCEJ YT'31`UECiCPs, 5U, <br /> G8 VL9 N !i7 <br /> AN11PA!4GE,;A-'� <br /> �`�iP}E�E�r�riEF3Cl:E~(Q� E'3�tZT`!-I/kI� E:-5i'�.iCPalhG f'Ef�F,�l'� A�TP(_1GA7'(UN <br /> . y lt � :.K%1' ansae:au- cn' sa ,tn•�'aef zt'a,: <br /> ,.ureby au56or.rn fk�rltlt r1?v1e ., :.... ,.,; I <br /> f 1sit:^`rn,ii l;p;.Y:.ai••n•:r•.:A; �(,•na:F 1cUane-�a,,._ r:,�.r,�,...! <br />