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04/213/2003 13:07 12e 5960 PAGE ©` <br /> 04/24/2003 10:37 20� ..3433 FTFTH FLOt]R PAGE 05 <br /> r. <br /> Fth <br /> n County FwWro /Haa�JwA o r4 Unit N WeR Pwmit Appiiaation Suppimmat <br /> SS: fX� PERMIT $R>)t;_ <br /> ak-2 <br /> LICENSE©CONTRACTORS DECLARATION LC <br /> that 1 am Ik meed tinder the prmftlons of Chopier 9(CommendW with Section 7000)dbivislon <br /> a and Pnofeaaicma Code taut my license is in tuft force and effect. <br /> 5 n Ihtr, 1130 04 <br /> Dote: ' G 3 C Cw: EliyI o - - <br /> _ 2 N� � �,�� s5oc14-res c.t%C�Z� <br /> Sfgnatura• L C <br /> Printed room": <br /> WORKERB'CONMNSATHM DECLARATION <br /> I heraby gift under penalty of perjury one of the fdlorrinA declarations: (CHECK ONE) <br /> �....I hwvv and%io maintain a oerocate Of corwtrst to soMinsurs for workon'apmppnt lNafy,ae Onwided for <br /> by SeQWn 9700 of the Lobar Cade,for the periwMence of the work for wMch this pemtit is Issued. <br /> I Fire and wilt mwn ain oro tin.ow"W'vetro"Isu'sn".as r0WMd 13Y GRCI on 3700 attire Labor Owie, <br /> for tho ia-fon g of the Work forwhM tbia permit 7s Aauud, iuy wed"rs'oompanaaMn k"WMCO <br /> GvMAr and policy ntlnit)erb am, <br /> Carrier_„� T� t r).wy N�a,v Policy Nambw: /6 //a a 2 — 61 <br /> S'�vS..✓ts�Nc� t`t�N� <br /> t ter**wt in the perfhrmanc a of the work far which No permh Is issued,(shM not empW pny penton in <br /> any ma nner so"W become twb*ct to the workers'cornpenwtion taws ai Cr+tifomia,and aQrse lhat if i <br /> should become 8uNft bo tt+e wiDfkers'oompwwatlpn provb6ons of Saaan SM6 of the Labor code,t shall <br /> *Xthwkh comply with those prowWons. <br /> / <br /> Prinord Name: <br /> WARNMat FAP-Vft TO 0=4 RE Wofii OW1 COMPENSATIOM COVERAGE IS UNt J1wPtl�.AND altALL BtJBJbCT <br /> AN EMW.OYFR TC Ci 1VAe P6u+►L7rEs,4rtR C1V11 fN!'S Up To ONE HU1144MEDTHO IRAWD DQUARS <br /> (""'000. IH ADO n"TO THC CMT or COMPENSATUJFK"rfREBT.ATTORNMY'S FEE*,AND QAMAQ"AS <br /> PROMED FOR IN 8=11`100 JM OF"M LABOR COM <br /> AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMrr APPIJCATION <br /> R "-- (Klgt a.nra.ffr Ace►rc 4 awtf*ruaed mpresantanw), <br /> hereby aufllortm(print++sma) <br /> W tion this 8sn Joaquin County Wed Pamtlt Applioatfan an my helreM. I unaefetand this aut trettsation Is valid for <br /> orw(1)rear nee r+t umrDert to the trork Plan 4040d on thO fmmt R"9Q Of ttdt appllcaSon. <br /> 84"2/MI <br /> / ' 7-to ' �� S r E� Rr2 f ED <br />