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r: <br /> r _ <br /> i � li•t1 i'f .4a . ' `ii� * 'ti' }'.'.' T� aw A f'r �� 7�'r r. <br /> 4{ LICENSED CONTRACTORS DECLARATION <br /> 1 hereby QMrm thtlt I aim IlceMsaci Under the provision¢of Chapter 8 (COMIrnencing with section 7000)Of olWelon <br /> 3 of the Business and PrWassions Cods sno my license is In fall <br /> force snd efr+oat, <br /> u4 <br /> Expiration Data: <br /> slgn'sturo. Mae .. �..�Title:. _ <br /> 6.r- 10792ar— <br /> Y6 ORKIRS' COMPENSATION 09CLARATION <br /> I hereby affirm tinder penalty of psrJury one of the following declarations: (CHECK ALL THAT APPLY) <br /> iY <br /> ' I hava and will malntair,a oertificate of consent to self Insure for workom' compenaatian, as provided for by <br /> $ectlbn 3700 of the Labor Code, for the pvrformsnce of the w'or'k for which this permit Is lssued. <br /> /I have and will rn.9!.r;tein warlceft'compenastion insurence, eo required by Ssctlon 3790 or the Labor Code, <br /> k for the portarmstior, 1f the work for which this permit Is IssUbd. My workers' compensation Insurance <br /> oarder end policy -;.bars ere: <br /> Carrier, �...,.�.� -.. Po4iay Number: <br /> certify that 1n the parfvrmSnOe of the work for which this parmlt is Issued, I shall not employ any porran In <br /> aq manner so as to became subject to the workers'compensation laws of Colifomle, and agree tl' 5t If I <br /> should become 6ubJ4M to the workers'aornpOrtastion provlaions of AwTon 3700 of the Gabor Cody, I shall i <br /> forthwith comply with thoss provisions. <br /> nate: a i .o $IDr1elW!'sl <br /> . . Prirltsa�d Name; <br /> VVA'RNilft FAILURE TO SECURE WORKERW OOMPENSATION COVORA0111)S UNLAWFUL,AND 8HAI.L SUBJECT <br /> OLLARB <br /> ($t Iq,00 AYSR TO CIRINITO YliI OF CQMPi�IKSATION,ND CIVIL FINES UINTEMSST AT'TO RI�ISSY�TEES,AND DAMAGES AS <br /> (�tROr000�,IN AgDlTitl <br /> pI%OV1DS FOR IN SECTION 3704E Op T S LABOR COD <br /> A lloonsed suthnriaed repressis%`AVW),1lerotay <br /> !, Z. <br /> au0hor{sa <br /> to sign this Son Joaquin County Well iI A'Aplie,001%on my behalf, 9 understand this mutherization is Ysald for <br /> ens(1)year and it limited to the worX plan dated,on the front pate of this appl#c*tiodt, <br /> 8.17 OCG-iml <br />