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925 313 0302:# 2/ 2 <br /> SZNT BY:91636223t8-Sac_r_a. , C• 6-21- 0 :10.38AM :RADIAN 1fYl'fRIbATf P 3 <br /> dor[gk n 6eb' sun �AwJe'rri, .phinint <br /> Joe xamfift <br /> LICENSED CON'T'RACTORS DECLARATION (LORI <br /> 1 hereN affirm that I am lberwid under to prodalons or Chapter 9(oommaw"Wth Seetten 7000)of Dlvlabn <br /> 3 of a%Busirm"end Profeiwaft Code and my license It in full FN and cNad <br /> Worm V. GC 7 %99+=_ ^expiraMon Date j,f 6/l4 <br /> wvwAulwr TNM:G Yl?/Il1rVl1* - Amo <br /> Amsted name:, Cf7IY , &mAmr- <br /> MYORKEW COMP11941LATION DECLJIRATIOHI <br /> 1 hanby al m under pwatly&,perjury ons or the fallowing declarations (GfECK ALL THAT APPLY) <br /> —1 have and wifl maintain s oertiGeste of aonesnt b aaNamuro far worlters compensation, ae provided for by <br /> 8eclim 370D of the Labor Code,for the perfomwnea of the work for vAlidi this pwmk Is issued. <br /> I have and wil ntain4W+Workers'ownpenaatbn Imurano&as raquired by Seabton 37M of to Labor Cade, <br /> -'br ow peR ww=Of the wwk forwhleh Ihis permit Is Issued, W workers'oompensation insurance <br /> owner end pokey numbers aro: <br /> CwtNw. jfg&a!�2 Polloy Nmrber. <br /> _I certly that in the parkrmance of aM work for whkfifi Na pemtk is issued, 1 shall not employ any person In <br /> any man W so we to become subset to he workers'wmpwnsa/on kw/r,of CW*Wf'An,and agree VW if I <br /> should become subject to the Workers'oompenaakn proftona of Section 3700 of the Labor Code.I shay <br /> forthwllh oompy wish Owes p wAimions. <br /> Cabe: f�Z��oo Signhuret50fwr 'eL <br /> Printed Name: <br /> WAR►alta:FAILURE To SECURE TMOtt1 W COW MiATION COYERAOC CI UNlAwFU ,AND IIHALL SUBJECT <br /> AN OMPLOTBR TO GRIM IAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (1100,000.),IN ADO MN TO TNI COST OF COM MNSATICN,INTERBST,ATTORNEY'6 PEES,AND DAMAGES AS <br /> PWOOED FOR IN SECTION 7708 OF TNI LABOOR,R CM <br /> 144"A ' iC aT kaeneedw hwtmd n wo"nufte,MnOJr <br /> tulhceNs <br /> to sign lhk Ban Joaquin aelady Well PsnYt AppNeallon oh wq bahW, I enlNwhni this rudmdzsuan to vekd for <br /> one 0 d lknitod to IN W"plan logo on Nle kw%Papa of lift app80alon, <br /> Z;Z al;ed `• 1Z:6 CO-EZ-��f'ZCEC CLE 5Z6 `• 'cuI 'OUTlsal V OUTTTTJO 568JU :As luas <br />