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AUG-24-2004 TUE 04: 16 PM TE & ASSOCIATES FAX NO. 641 9222 P. .03 <br /> t ► . 3 �,. <br /> gem "quln Ceunly mrlrumnen4l Health Depanment Unit wWag Pernik AppNoadom 8upplemart <br /> .los AooResa: 3650 N. ✓� �.( PERMIT Sft <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the pr0vlalons of Chapear a(commencing with Section 7000)of Division <br /> a of the Business and Profesaions Code ane my ncensa is In nN torte and effect. <br /> Licvrtae 0: 612268 Expiration Dale:_XW06 <br /> trate: 1 Conrac poctrum Exploration,Inc. <br /> 8rpaatult: Title:_Operation lllanaW <br /> Fdf tad name: Brenda 6favllYlrtl <br /> WOPKERS'COMPENWI`110141 DECLARATION <br /> I hereby affirm under perm of perjury one at the followtnq declaratbnsi (CHECK ONK) <br /> I have and VAl maintain a cenwrate of consent w asilr4naism for worKers'compensation, as provided torby Sorlion 8700 Of tho Labor Code,for the performance of the Work for which this FwMit 1%bared. <br /> x I have and will malnWn workers'mnperAalion insurance, as regWW by Section 3700 of the Labor Cede, <br /> for the performance Of the work Tor whim tris permit is I86Ued. My workers' oompenWon htaurance <br /> arrler and policy nunlbclu arm' . <br /> '4rrie National Unlon Rhe Insurance Co. Policy Number,GM303 <br /> 1 eertrq that In the performance of the work for which this pmmft Is Issued, I snail not employ any person In <br /> any manner a0 as to bemmd subject m the wnrkes'compensation laws of Caftmia, and agree that if 1 <br /> should become subject to the workem'wm n provisions of SwIlon 3700 of the Labor Coda I shall <br /> f0rlwft comply with those provUllcns. <br /> Date: _ 811411 D� SFgnalitrw' <br /> Printed Nana:__Brenda CraWfbrd <br /> WARNMIG: FAILURE TO SECURE 1NORI®RB'copipp[NSATIM COVERAGE IS UNLAWFUL,AND AHALL 81.1111JECT <br /> AN MWLGTER TO CRIMINAL PIENALTICS AND CML PINES UP TO ONE HUMME13 THOUSAND OOLLAM <br /> (1111il0AD0.L IN AVIDMON TO THE COST OF COMPaMATioK.WFEREST,ATrVRNET'S FUM,ANn DAMAGES AS <br /> PROVIDFD FOR M SECTION acus OF THE LASH CODA. _ <br /> I_ON FOR OinraR THAN C-67 SIGNING PERMIT APPLICATION <br /> (,_P1r- Ua7-ZT.�ln.^r ei%ploraaori,Inc(eiatraturc olO-0J Ilcereed and nariad reprao+titM), <br /> hwehyaual dw(print Move) Mi ICS A'hl101SOk_ 6P 11 n0Ii P-Syrt7UaAcs <br /> fro clan this San Joaquin Ceyrlty 1N*If PemrR APPnostlen on ICY bents. 1 understand!Me authok"r ed a vend Tor <br /> ors t7)Year aril le Ikmilad to the wok plan dated on rhe IMM Nago at aa.WWAL &tl L <br /> 1�7e-p1 J W <br />