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--- ♦u conn vrKUNEX INC. 5105687679 <br /> P. 2 <br /> � 1 <br /> I <br /> inE <br /> ~ ffeafth Saftrksa,UnR IV t1yeU Peftr"t APWIcitlOn kimem <br /> JOB AouRFss:_IS ALL <br /> PERMfT SMV. <br /> LA*i%vNy Cfl gS3�p <br /> uce SPP nnarn ...I LI DECLARATION rpj I <br /> I hereby afNrtH that I am frog ar+aed caber the Prions of( Ia <br /> 3 of the Busigess and Profeysiaro Code and my provisions nso Lt In Pl Of 9(commencing with Section 7000)of Divieion <br /> LicemieaR: �0 a force and effect. <br /> Expiratl Oats <br /> Date: Z O J <br /> Contractor <br /> ! <br /> �limabrn: <br /> print"demo: <br /> WORKERS'COMPENSATION DECLARATION h <br /> I hasty affirm under <br /> pMtY of Patjury one of the following derlarstioes; (CHECK ALL THAT APPLY) <br /> _1 have art?t0@ mor'bli t`8 eerUfk al"of consent to salti�sure fbr workers•compensation e6 Provided for by <br /> /Section 3700 of the Labor Code, for the Performance of the work for whites tbis soatpermit b issued. <br /> rL for the 1 have and wIB mairtain,:wai Of the Orr r w oensal insurance, as requil by Section 3700 of the Labor Code, <br /> carver andkpoliey numbers am. which this Paeeetlf is owed. ll workers'eomPansation insurance <br /> C aul e. Gr7a.n; 1t✓i 1 r 1. r, �, <br /> Pofky Number: 4 a c> <br /> I 00r6ry•Ihat in the Petkmrnos of ft wwk for which this <br /> any+Hooter so as to become subject to the wodam. Pen sa o issued. i shall not .and agree eery Parson in <br /> should become subject to the workets'comp*nsat*n Prov $etc n 37 the abcode, if I <br /> shall <br /> *NUhwish eompy,with those a Pnprigions. <br /> 011e: _o'j —a+ » o:� gtpnature_ ` <br /> r ' <br /> PNnted Name: <br /> LAM <br /> -.FAILURE TO SECURE WORKERS'COIIPEMSATIOp t�yE <br /> YER TO 6RaRINAI PEIIAL7iF3 AND CML F1NlS UP TO ONIOE f3 UNLAWFUL.AND SHALL SUBJECT <br /> 1N ADWY1pN TO Tt1E HYNfiREO THOUSAND DOLLANS <br /> FOR 9t SECTION 3700O�F TH CODEIN'fFRE9T.ATLOitNEY'S REEb.AND pA1MA0E3 AS0 <br /> 371fCsesed suUherf>osd rspressntuih sfMreby Mdhodaw <br /> ------------ <br /> 4artJoaquinCora4gr WiW Petteat APpUenion on mdrat b nmHed is*01 wmk n dstaa on the r behalf. i trndersfan"fttb au9twt6e9en b vdle for <br /> h irerm W this 6 <br /> I <br /> I <br /> I <br /> l <br />