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Z002 <br /> awt <br /> San Joaciuiri CountyPERMIT <br /> t:nvirortni•�rltc'.I EisSittr Del�artmet f (fn't Ell Y�'ell {'er�»ifi,r<p ;lir_ar( r, `��Eti/lt mr+;il <br /> JQB ADPRtS�.._U, — <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hsleb ;,ff�mt that I am licensed undcrthe pravisirtns of Ctiaptug(cr>;ntttencing with;uct IZ 7pQ0)of CiiVisiCn <br /> Y <br /> 3 of the Dusin�'ss and F�rofe'Si n-c i>de ono my licpiise i;in full force /and Iters r <br /> License M 'run r46; <br /> _.— _ .— E}•N - <br /> prihtecf'rtarne: — <br /> WORKERS' COM PENS"ATI DECLARATION <br /> { lr�rr;by aftinn urider pc_laity of peduty ono of the following c;r aFatkms: (CHECK ONE) I <br /> { fkave and will ,,,aitKain:�c cr(tficete of conse��l to self-,elffor woikr•_r�'roml,en!;,-Aion. as prcivtGeG fvr <br /> by S=tioti 37'()0 of the Labor Gode, fru'the pErlt�mtianc� of file work for.whitgi thL'potrni(is issued. <br /> i have and ti,rill��" "WO1 eta cvnipe.nsatian in utanre,,as+cauired by 5ec(enn 37U0 rat hie Libor Ct�dr, <br /> fd.the periormanoc r�lif>e woFk.fvr which this permit is issued. MY wuricers'compensa(iori insurance <br /> uaniat a p$licy nutty eta r-'�( D <br /> Gamier: � `.J .�� —_ Botley IVUml�pr_���✓�I.�.-�_--- <br /> E c-ertify that in the pert r7i1w>cx-of tF►e work for whic:li this.rsetmit Is issued,l shall nat urTIP luy any persoi Or <br /> b.ny rrimnner tm as'to lie me zAeO to the woricer-;'compansation laws of c:alifornia, and agrtie that ii I <br /> should becomo sAQQt to the workers'comPei1S un provisions cif Section,3700 of(I ie Lat m God e, I h:all <br /> forthwith Comply witll those pruvisiom. `' ? <br /> Dstc: <br /> `Y+ RWING:FAIL IIRE TO 5F•'CURE WORKERS' c()Mr-*ENSATIOi'•l coVERAGE V;IMLAVIf-rUL,A rj S4ALL S'UOJt M <br /> A;N LWPLOYER.TO MMMAL PCNALTIE3 AND CIVIL FINFs UP TO o:Nl::F)UNDR6D Tt Ie 111.%A D DOLiARS i <br /> (£1oo,Doo.),IN AODiTION TO rH�COST OF 4OMPQNSATION,IN7xRES`f,AI`rORtdirti.,S r EE`' ' f�kN AGE; A <br /> PROVIDED FOS.1N SECTWO 3766 OF-mv I•A;sta•CODE. <br /> A.—, L <br /> f E l t(3 fl THAN C,5? F�FIi{tfi4`t' ,�(?{'p,li,�S�I(7e`«—. ... @rl5ncj Y._ -. - \��' Ltzl�_�-E". U1�.L �fi ,lkSS o�1 ETES _ , <br /> I'tyreY�uthuria� tEsp'Ini riatttfl)�..1L — - - — <br /> I r. �l^�!: ••!-`. .! .N�t t1;.C:h!L„tiv �fn�(r'""(111.�:El fl1!(::-!�ir.t. olt F,% br tk@'i; <br /> `•F,.Yt i,lf'i,lt'. _t ')rtat..•f .:1'ri:, :1':fd:<t,)'; t!.;. ;. ..,.t „'.1=h C.`.'.r:is dr,/c7;."Iat`. <br /> i ' <br />