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_ 16002 <br /> an.laaquf❑county Envtrottm•�ritzl Health �eDartment unit IV Well Peru-tit Ap;ilicas;pn 3ett„Irmrr;it <br /> F—S <br /> - aRFr <br /> JQB ADRRCSS'.= L`5-_tJ' Grmk " wJh <br /> —' — <br /> LICENSED coNTRAC'T'ORS DECLARATION LCD <br /> I hereby of irtii that I am licensed under IJia provisions of GtiaptLt-9(ctunmendng with•reel n 77W)of[ iv sion <br /> 3 of the OUsiness�an�A�H/�rcfec(sI -Gude and rmy Iicer se k in full force a,n!d Mea <br /> Liceisse� _�� 4 V l� i Ejry' �lr�fiannctc?: <br /> can <br /> Dow <br /> Printa4 nafne: <br /> V ENST13fl DECLARATION <br /> rNfltikGErYS CO{vEP <br /> I h*r by aftinn Crider p ally of perjury ono of the following d ularatkms; (GHE'GK ONE) <br /> I"have and will mainfajn a wfiificate of consent to self-insures for woikPr.'comperr>ation,as p,uvided fol <br /> by SecLou 37'00 ofthe Labor Code. for InIe perlcrrttanm of file Werk fot'whn,4i thi:parmii is issued. <br /> XI have.and Will maintain workers' mmiptinsation inuuranre, „s t'oquired by Geobon 3700 of Hie Labor Code, <br /> for the p�torrnetnw.oftik.work.fvrwhich tNspermitinissued. Mywuri/u►rs'co{�m{pensatoninsurnnce <br /> t,-,antetarxxpolicyn�um iar�'`c�(�,�J fr." 1 �� � �DO <br /> Carfier: CC_S,«'y�' �-j==i-- Policy Number_�L lam✓ �.,—,—.--' <br /> I f erM tllalt in the peribirtlau>ce of the work for which thmpetmif Is issued.I shall not wnploy any persor i in <br /> any inarnter u asIQ bewttfe sutiJect to the Waked cornpensalion laws of California, and aagroe that if I <br /> should become subpxt to the workers'compeiis bre provisions of t coon 3700 of II ie Latxx( ode, f 'hrt!! <br /> forthwith Mrifily`A111 thos-pruvistont- Au <br /> —_Signature:Printed. Name: �Se,.�--'s/s-Mfr-�y —— <br /> `WARNING:FAp 11RE TO sriOURE wotzkms, (%V MPeNgATlON COVERAGE IS f1NLAWFUL,A ra MALL 5'U3Jf�G'i <br /> AN INPLOYER TO CWMINAL PENALTIES ARD GIVILFIRPS UP TO OWi HUNDRED TtfOuSANG COLLARS <br /> ),IN N AUI IION TO'17115 <br /> 7oC F? or lLp;i ii <br /> O Mc jAnON•INTEREST,AlloRNEY'5 I'-GES,,+r:O 17ANtAGE;+A`< <br /> PROV E <br /> Fhlf3{t4�r++Tl id-f^tx?i� mrz- <br /> THAN 0x57 :g0NINrpFE+Mlf'RE`FL.lL'ATIO <br /> „—,_, � fslflnawryt gfi%sY IiccnsniF nutfinrixrd rat>r!:5entn!iYa), <br /> C-'1! �J t# IkSSo�t 94 TES <br /> hyretty rutiwri��tlfYlnt nxanet—...JLvI=�mrYG_�.i�UJ-!.� <br /> '� ,, n fhs Fqr, �n.ar;uln r;rr!=v'aiv tN>If:>�rmif i:pitL't..:S(ra, ru iii Lvhaii S t:nCF.:raf..r:d rhi:,n r- <br /> ^I;S <br /> I [ . n,nr.:,i n'iNst;IPM4H t•Yl !'a" i"'r'i, ,'.,`.p rev i1:i:, dLIN!."Clili.., <br /> i <br /> lraf-l�F rn;r•i"a i• I'3,It.'i:: i � <br />