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y�y�ic—roc .c+e74 I ! :-deOA t FROM � n,e �-y+n CI q�, ` / �n P � <br /> r-:ir-c 11na _r:r0 I')'1�jS �/ PHONE. NO- G W� E38 1?� 3 .Y0 2e0j I2:27PM P2 <br /> :3all. aaq►riat Catl#styvlranl lant�l j.Qth aopOrl nOnt Unit IV ftft Permit Appficauon Supplement 7 <br /> JOB. PERMIT SFS:_ <br /> LICENSED CONTRACTORS DECLARATION .(LCD <br /> I hereby afhow that!am icenwd under'he provisions a!Ct:a ter p ,, Mbnci , <br /> C <br /> A 4 .m rg tivit!t 5Eotisyn 7000)of i7iv�sipn <br /> 3 of the Bumnass-and Pmfvzrions Code,and my lieto5e ix in full fryrthl,and of tct. <br /> t.irenrrr p; 71 <br /> E-Apirat+ar C1at6: �� <br /> Signature: �..,._., ` YTit1P' f r• _— <br /> - t <br /> E <br /> WORKIERS'-.CGNiPE11$AT!OA .DECLARATIoN <br /> I h6reby Affirm urWvr'pGn1K)f of P41rylary nhe of ft fo00*09 d4claraWns: (CHECK ALL THAT APPLY) � <br /> - i Have and mil maintain a cer4f ate of CCogent to sell insure for workers'co►rpon$aticn, as providp4 for by <br /> 90-m n 3700 of the.I.abar Code,.foe the perfgrmanCt Of the=Work for whi, fh th; <br /> Is permit is ia5ueci. i <br /> r <br /> I Zi havd and WO rrlwntain workers'compersetron iri$Wance,as req�oked by te�dan 3704 of the tabor Code, i <br /> for the ueftrManCe of the+work fpr which this Permit rs issued. My workers'��a W$ation insvrance j <br /> caer and policy number are: <br /> rri <br /> '. Crterrlar:'. PalicyNumber: 15 ' 3 TCS <br /> I celti 4t'i.'it in'no r1Gr'mance at the wv:k for WAith this permit is issued analt%not employ any persoh in <br /> anyrra,wr}er so as to Ism me subject to the v ers"corrzperssatiori laws of CaGfamta.and ague that ir f <br /> i should ImCome sub;ect b the wrrrkers'cmrnpenSjifq¢n prrivisic.ns of tk),n 3700 of the t,abar trade, I rival; <br /> E fgrthwith eompiy.with those provisions <br /> I Pr'iMed#Varma: <br /> WARNING;FAit_UFM TO SEGURiE W0RKER;5'GQ.X1MN!;ATI0ty LpYL-F{AGC.IS UNLAWFUL,AND SHALL SV15jaGT # <br /> AN E11i PLOYPR"10 CRM NAL PEOIAL fIEFi AND MIL FIRES UP TO CSE HUNMED THOUSAND.POLL LRS { <br /> 4 400,000,),tN ADi]I7 09 TO THE COST OF CQMPERSAT ON,INTtRee r,ATTORNEY'S FESS"ANIS DAMAGES AS <br /> iRMDEV FOUR IN TIC7N 3706 OF THE LABOR CODE, <br /> I, ;j dl 1, r 5 #�- _tri twtum d[C-57 li32rn wd authorieod <br /> H rBrAyar4t6dsve). <br /> hentr;!authorize.(print r+amal,,.,,. 4F <br /> to signs thin S*n Joaquin Gaunty Well Permit AppdicwtWry oo my kCthetf. I undemtwd this authoftoMm is v"d for <br /> une(t)year and is hmited to the work Oen dated an the fnnrtt page of flim app7se3tivn. <br /> 1 l-?b.0a 1 Mi � <br />