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.r Kim-27-ge 12 :16 PM P.83 <br /> I-:lio^a4Clrt;d 1;1''aQpl•t FRIjIA P. a <br /> r • <br /> s <br /> Sett Josquilt C4ut1ty vlrow"MAi Neakh 3erViess,Unit IV WWI Pam*Application SUPPlrrnent <br /> I <br /> J019 ADDRESS: R?aD A #AGK+U I��' LAT14ge PERMIT 6R#; <br /> LICENSED CONTRACTORS DECLARATION ( CU) <br /> "mcr�ty atT m that I am kensed under Oo proviWns of with 9ecdlon 7000]of Divlsb " <br /> �I 1-no SU"ta "S14 aaxl Pmp-sans Code and my Ilra:noe:s A full forolo and effect, <br /> L,ur-nse* C �J iQXa'iracon vate: <br /> r �rl lk' CrOn�YIxCJr•r amne // � zff- y y - <br /> �#aVr7atura' Tltlr( �►1 ��/��G>�' ' <br /> P'rintsd name: - <br /> WO RKtRS'COMPENl3ATION DRCLARAMN <br /> t.ie)reby arfcrm under frertattar of perjury one of the fdaw.Ag decdBnsdonx ICHECK AI,.4 THAT APPLY) <br /> .I hilae and W mmnlwn a caMflcoto of m omwt to self injun for ww%*ri'oom0ansatior~.as pmVided for by <br /> Ecdor.3700 of t*Labor Gods,for the prffprniarf a go tftt work for which this perm t Is Issuea <br /> t lure and*49 malmain wor wm*Compensation in surmen,as m4ulred by Section 37DO of me Lawr Cade, <br /> for tfta pwtirmance orcne Work torwrwi Mil ormlt is lesued. My waftm,aamenwiorl insurence, <br /> currier and policy nnumtws ora; <br /> C.vriar.W <br /> Ale- c*.r►a7/1G .Palfcy Number- 0 <br /> I Larify:hat In the vett mance of:he*a*fol which Ws pumll is issued. I el ill not employ any persue in <br /> ary !1%l Arvr so as w beccknw eu0}e0 to tht were an'eomponsat on laws 01 949dorrlin.and agree that If <br /> vac uld:=orTfl:subJed to the ward aW comper wgion urr vwan5 of Section 3700 of the Labor Code,I shall j <br /> fhrtMml`zamply wllh Moe provitiont. i <br /> ' c' 4� I <br /> Date; <br /> tlslprtARuro: <br /> Prinftd Me "I P" <br /> ' WARKINg;f4lLURE TO SECURE WORKERS"CLi 01111iaAT"Govt mft IS 11Kt.AWPUL,Aima SHALL susjacT <br /> AN FMPL OYER Tp t+e11PARIAL REKALn**AND CML PIWX UP TO OW HUNT WO THOUSAND DOLLARS <br /> aF'jjv,0W.).W ADDITIOM TO?Nit C 08T OF CO MPNQATiON,WERIEST"AncRmINIS FEES,ANO gASIA0E9 AS <br /> 01RO14l ED FOR tH GCCTfOM OM OF THE LABOR CODL. <br /> e 1 { =�'� i" u��✓� IC�t:7 IlcomeO irlRhoftlidl re irOmnWirt}.beroby <br /> i <br /> i <br /> to vign rhfs San Joaquin Coungr Weil PwWTtAaspO &Mw et+sty behaN. f umlenfler►d thin audicriaetiaon Is valid for <br /> u+ma t>>boa.end Is Him ilM to the work than dated on HMA front Paas of this wplW;&0vn. <br /> wv abed `LE EI 00-ZE-uer `2'dE0 E1E 5�a `• 'OuI 'BU-1 _sal V 6uTTITda 66009 :r(8 a_uaS <br />