Laserfiche WebLink
............ ......... ....... ...........--........................--.......... <br /> quin County Envirwintilintal Health Dapartml Urd,IV Wiwi Painnit Appticatic S <br /> ltaplement <br /> J08 ADDRESS./000. gfH WW� PERMIT SR#, <br /> LICENSED CONTRACTORS DECLARAMN <br /> I her-00yaff!rM that I am liceh too Linder the proryiNjohe of chepief e Irommaitic-ing ii'llb SeVon 7000]of 01 <br /> Vrg!p.n <br /> I of the alinialess,and Prefewinns Cody aril my fice-nse,is in hiij for.,-P and effem <br /> L U 6 .2 <br /> —------- Exwaiti"Date- <br /> Date f <br /> 1,orilraciorT" <br /> Firintiou nafrie: <br /> WORKSRS'COMPENSAT,ION MCLARATION <br /> I narr§Vy affi"M Under Danalty of pe-jkfty one of the f-Womrig decivall is: <br /> (CHECK ONE) <br /> nai,'e and"'01 11,wrilaln a cer"llica'o of consent to Kficlf-insurefor ae provided fed <br /> t!V S -folf%f!7-00of the Lal�o,'Code,for 2he Peelornria;Q 0,ih,WwtR 00r`V"V*0A' IhiS Pe-Mil M v8519111(! <br /> ;And Will M.MnUln as fRULWed by Se60";3700 oft, <br /> in, Ile <br /> I perd.ornlarece oftine worl,fot which tirls pe"niftit"itilikled, My wo?kii's, <br /> I,�;trdaF andpitellcy nurridgwe see <br /> -".pollcylihimlaw: WIC <br /> Carrter� <br /> I cer6pf mot in III,&wfor"nance of 014-Work for which this povoill,is msuad. I uhali not employ ani, piemon in <br /> an,ma,-'ner so as io tLe-wril#Sub ed.0 thalawker4 laws of Qalfb Me!and aq. M;Ilmali W <br /> kji <br /> " ui-beru��-If,$k;bjo--'4 to!h*m"'rKers,compe-fiRtiar"P-1-0111114w,"'I's of sercion 1 M of the Labor <br /> 1^vviw--44"coilioly with !);oiie plovisla.-ris �?I.. .......- <br /> . ... .. <br /> ftoiratlon Date; J., Fy V'4 S- <br /> ............. <br /> at <br /> Firmted Name: <br /> WARMNO!f AlLUR9 TO SECURE WORKEPS'COMPENSATION(40VERA-a IS UNLAWFUL.,AND SHALL$1.12JECT <br /> ANEMPLOVIhA TO CRIM111ilihio.PENAI-1190 AND MIL FtM*S UP TO ONS MUNDR90 Y14OUSANP 001.1i.ARS <br /> i.M ADOITION TO THE COST OF COMPeNfvAT*N,INTC.PtMr,ATTORNEY'S Felkii,AND DAMACE-5 AS <br /> dAtWIUED FOR IN SECTION 3706 OF Trig t-AaoR CODE <br /> AUTHORIZATIONXICIR 9.THM,.TMAN C-67 SHMING PERMIT APPUCATION <br /> .............. <br /> igilisna we WC4417 kdn"d authorize,'toomfienravviij. <br /> FdcKr..................•. <br /> to 419n this Sim Joaootn C-.1uA%l Kali Perviliz Application on my bahaV. k kimclomitaind this.aut <br /> on*0)year and is,limlliad to Uic-w.rji plah d3t*4 oil aie front page 6f riliq opptionliqn: <br /> ........... ...... <br /> 20 'd 22:ZT SOOG7 6 AON 906V:S90TS:x?j <br />