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-..••. ,m. —. vw v' a leauny, incl tlZn 313 0302; Nov-18-99 11 :23; Page 112 <br /> 1^11/1S/99 THU 10:32 FAX 310 093 13 CH211 HILL Q002 <br /> I)-WEr '1999 11 :42AM FRAM � � �'A <br /> r <br /> sen Joeq County MwAmmapntel Naatth Unit N WaH PeeME Applloatlat 3upplmW* <br /> JOBAafaREM 1LD FfcaEAT' IERRINT SRP9 <br /> LICENSED CONTRACTORS DECLARATION <br /> 1 hasty affirm that I am IICarvwd WMW the pfwAgi na Of t h"f 9(60010114Mft with Sec*0 7000)of Division <br /> 3 of the ankmom and Probation Code and my ken"19 In MR rase and sllact <br /> Ui nnse e. (Jc% 40? emkosm pate:. J0131 /2--opo <br /> Osla: l lj tj�p cwvamc ISC"r-I eA Cmr f 1/l.� <br /> swrAturm. cul( , Title, 101 J/l"e&- <br /> Ptinl9d name. N sJ Rr oe� <br /> WORKERS'COMPENSAT)ON DECLARATION <br /> 1 tweby ass under penalty of pe yury One of the buow v dsclaral rw (CHECK ALL THAT APPLY) <br /> _i have and wN1 RMkKahl a certNOete of consent 10 Sed4nstue for wodoW CornPensalloft,as movided for by <br /> SeCNOn 3700 of the labor Code,for tfN portorn w=or a10 work for which this perMt is ieeued. <br /> ZI haw and wM ambitaim WofMW eanpM9a3on insurance.Be MWred by S*oWn 3700 of are tabor Code. <br /> W to pedormence of the work for WMah this}w"*IN issued. My wodaow ComPanswoon Insurance <br /> Center and p09cy numbw*are: <br /> C.L. C'od- GD rv-1,f Peroy Number•_roO49 1 i0 493 4 <br /> _I ow*eet in an per ommm a of tfw vrotk for which th%permit is issued,I sheN not empty any pwwm 10 <br /> any ammer so w to become tul"d to fres vmr"W 0wnWsafien levee of CaNfomle.MW a"M*if 1 <br /> should beCOM Su1000 to the wankare'oompansetonprprovissions of SeCllai S of the Labor Code.I WOO <br /> forallrktl comply with phase provlsiona. ,/1/ 7 . <br /> Date. 1 II Q1 1 Qq signature; A -- <br /> P Mile Name._ W011&4 LJ At Ae� <br /> %VARMIQ FAMURE TO SECURaw011130 lt3'COMM""MON COvaRAtsa W UM AVR%H.AND 3NALI.SUBJECT <br /> AN®WLOYER TO CMINIAL PE4AL7flS AND Cfl9L PINK$Up TO ONa"MoMD THO AM DOLLARS <br /> pla"N.L US FORADOMD"To THEION 3706 rTt1E WO ��I T.AT rORNEv'S Fkta.ANP DAMAd-9 AS <br /> PROVKM <br /> L M a fV(,r ,(d e-r� (C-0 Hooted su*wdWd mWOOsntsavel.hw"y <br /> to s10n"s San Joagwn Cow*Me Pemnit ApcNwcOn en my bwN. I understand Bus auOlertratOn Is vaNd for <br /> ens 7 rand iv Nmlaad 10 pts www n dated on the of tMS Nan_ <br />