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+y- TFLLS -�E:KL ;:HLt_P1...51f1—DI- 1 I L :G4)9`SJ 3 <br /> J 7 4.71 f4• ...-!�[ •+ww.�.+w�.y..�r,�..�.-rrar►.A* ., <br /> 1'/\�� w1�M...r�+'Awll_ yr.a�.«M....�.,.wn�.• ��•IM�i�M <br /> P. 2 <br /> Sun Josqutn Countynvirortrrlsntut Fleafth Survives,unit IVa Parini Appiid4111on Iupplsmsnt <br /> JOB ADDRESS: 31 <br /> PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION ESR) <br /> IOl`1 htraby ernrm that I em licensedunder the <br /> �+ <br /> � previelorl0 Of Chapter 2 (COMmAn inp with Section 7000) of Dlviaron <br /> 1110M <br /> Date:.ator: <br /> signature: l---- <br /> tt� Tige: <br /> Printed narng: V t V►1 <br /> R <br /> WORKERS' COMPENSATION DECLARATION i <br /> I)tereby affirm under penalty of perjury one of the fallowing 4904a rations, (CHECK ALL THAT APPLY) <br /> 1 havo and will maintain i oartlnnAts of content to teif•inoum far workers,compen"licii 1,aw Isuvlded for oy <br /> Section 3700 of the Labor Code, fvr the iperformanee of the work for which this permit Is issued. <br /> I have and will maintain workers'0001punsatlon lnvtironoe, as required by 89000 3700 of the Labor Cotte, <br /> for the performance of this work for which this w <br /> plrMit is istlusd, M)► arkars'otimpehsa,nprr IA60rAnce <br /> carrier end policy numbers oro: <br /> Carrier. Popov Number; 'LA3S K3 -2 ,(7112 <br /> ��I ..ollfr 0lot Iii I++a liviAx inance vT inn wrdX UK Whitt thip 1114 h Mr iAllil�n r,ni Iwi��w�I�� <br /> M � St1a1e,w1 lil <br /> aM1 w H1r1iW!!11 sunleac tsy tnr •t'e 80 <br /> L�„v,, � p .i/ U Oi L <br /> ,a vits�,.�V 41118wuIRpis A4h t10f1 pro �" � at1f1 itfl'itY lilt if I <br /> fnfthwil 1 t. <br /> V1111 <br /> ICY of11���f1S he Labor Code, I Rhail <br /> vara• � fitEntlturer <br /> rrintutl Name: 11'1'1 � .1� �. ' <br /> watennrar FAILI,iRR TO seCuRe WORK11 lze'CoMpl! +�A <br /> AN iIONvt3RAaE I$Ul�fir►wt=u�,AND prtALl sue,tscr <br /> IMPLOYrEtR TO CR[>yttMAL PENALTIES AND CIVIL Ping ION <br /> UP TO ONS HUNDRED THOUMNO DOLLARS <br /> 191100,004.),IN ADOMON TO TFIS COST 00 CONIPiU RATION.INTEREST,ATtORNEY'S FEIZ3,AND DAMAGES AO <br /> PROV10110 FOR IN SECT*"3704 Op "M LA99M COOL <br /> (C.67 lieertssd euthorized roprwsntstlw),hereby <br /> euthorl� <br /> to*'On this 00h Joaquin Counter We11 PermitApplloogon on rely behalf,' i undorslsnd this authoriiwoon 16 valid for <br /> one 1 year and It Ilmlt*d to the vvortt ptan dated on the front ►of this a tloMgwn. <br /> H0 0 r E 19z SE8 609,' 66-V - i l `•nnU103d5 :A9 1N39 <br />