Laserfiche WebLink
taw <br /> c/cK+r zurpi 10:.s r Yb7"7 ry_L'1'L5 MUUL51 U A I(, PAGE 03 <br /> Un Jomiuin County Erna romeittai 114"Ith Sw Vtces..knit tY Weil ftffllit ApPCCA i4t►SupPlchteslt <br /> .JOB ASD�RESS: � � W, Gvr"A�140L PERMIT SRO-.-. <br /> LICENSED CONTRACTORS DECLARATIONL( CDS <br /> I hereby affirm tttat I am fitensed under the provisions of Chapter 9{Mmmencing with Seetbn 7D00}of Division <br /> 3 of-the Business and'Professions Code and my 1"nie Is In fu11 force and <br /> Um nse P. 0(0t,atpiretion Dad. 4"3 <br /> Date:�,�-� ��.�. coritrstaor: n✓d r �)m 1'1 <br /> 3tgnreture•_.. W Title, <br /> Printed name: t.5ul _ i <br /> WORKgRS'COMPENSATION DECLAItATtON <br /> I hereby affiant under peralty of pe4uty"of the fo]WMng dei isrstlons (CHECK ALL THAT APPLY) <br /> 1 have end wlit rnootton s cartrticste of consent to self-insure for workem'cornponsationt.as Provided for by <br /> Section 37M of the labor Coda,for the performance of the work for which this p mitis issued. <br /> hava and will maintain workers'compensation inturanre.as required by S*cW 3700 of the Labor Code, <br /> for the perfoM&Aeo of the work for which this permit is issued. My walkers'em pensaftn Insur*ice <br /> carrier and policy numbers are. Ik <br /> Catrrier:t �1"Y - _ Policy NU.4 es: 4141d <br /> 1 certify thst in the pe.ebrrnance of the work for whi6M this permit is Issued, I shalt not employ any person to <br /> any manner so as to btcomo subject to the workers'compensaation Isw!Of California,Vid a orae that,It I <br /> should becoMe suNect to the workers'compensatlon provisions of Section 37,00 of the Labor Cade.I sh*t <br /> forthwith comply with those provisions. <br /> t3><te: »f2a SiDnsture: - <br /> Printed Name: 7 ly <br /> WARNING:IvAILURE TO SECURE VV01tKFR5'C0MPENtSAMN COVERAGE IS UNLAWIF",AND SKALL SUt?i.= <br /> AN EMPLOYER TO CRIMINAL PSNAL,TIAS AAIV C11iIL FINN UP To OW OfUNDREU THOUSAND DOUAKS <br /> (V00,000.).Ihe N ADDMOx TD TCOST OF COMPENSATIKK INTEREST,ATTORNEY'S FEES,AM DAMAGES AS <br /> �;G11 s POR IN Bt:CTYON.3T00 Of THE Lmlaft GODS. <br /> (C-S7'ftt" ed autheriard rep4s+ntW"),hereby <br /> wtA�oris� <br /> to sign thls Sony Josgsifn Caurity Well Permit AppNcadon an my bahaN. t uneliitatand this stathari421166 Ls valM kw <br /> one(t)yssr and is llmttMrd to tM Wank plan Idaud an tAt front pogo M Vft aWcsttan. <br /> I VJOa� HUES: I S66 t—6Z--9 <br />