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San Jeequin Gott"ErMf onawn t Hnstth Doprargnm t Unit N WON Pannft AppNcm* a SuPPlit <br /> ,JOB ADDRESS: PE=rr SR S <br /> LICENSED CONTRACTORS DECLARATION ( <br /> "C) <br /> I hereby affirm titet I am licensed under the provisions of Chapter 8(comma toing with Swbn 7000)of <br /> Division 3 of the Budness and Profemions Cods and my license k in full t"No <br /> erfxt <br /> Lisensm Ir:: r 01 O E DetQ: o i q <br /> Deft: ` 1 CU C�arttraC*ar 1(I �� <br /> Sfgr>ature: Titte: ces <br /> Print Name_ _ ,l <br /> WORKER'S COMM01fl DECLARATION <br /> I hweby sgrtn-under Penalty of p"ury Ong of flee folkwing declarations:(ohaak ones <br /> I haw Brad will nuftbin a aerffkale of consent to Oatf-basun,for woy kaW cornper"tio"'as <br /> provided for by saWon 3700 of fm labor Code,for ttae pavfon canes of the work for which this <br /> Perm*is issued- <br /> 1 h"a Wd wig mOfth rsAM'oompensabon insurmum,ac required by Godon 3700 of the <br /> Labor Coda,for da Perfonnaoaea of frac work for wMch this pem*Is Ism. My workme <br /> oorr"'" !n and pt>gcy ntirnbelas aro: <br /> Cannier,� M Poi Nurn <br /> 1 oortify!fief In the POdOmmfice of the work for which the permit is issued, i dull rqi er pkry eirty <br /> Pemn in mw manner ao as to become wA*d to tyre woyiceW mnpet�pn few of Caiifpmia, y <br /> aNnee thah <br /> If f cuid INMMs subject to monk&& caaipemae� find <br /> LaproWmipras of Setdioas 3700 of the <br /> Labor Code.I shag foy�tlwft those <br /> Exp. data: I 1 Signature: <br /> Print Name: t' 1'C. <br /> s{aye{ ro saourae wnou t It tNe.+�rwaat4 rwo WALL r AN <br /> tee. arro orvr, nsass W ro s+4o,Ooo M ADC rnM mTM CMM QF rrr re <br /> ATTMIM M.Aare DAMAGES As�rM yaaarn ssetaoa neon taf'ry:t yrs;DWW <br /> 1, OML <br /> OTHER THAN Cep SIO NNG PMAT APPLICATION <br /> of C�7 used <br /> h'e'ohy. �{Print eeansf � ., 1• <br /> &Wn a&3"jmgwn oftraty wen Permit cna .to <br /> y behalf. t undwobow Nib valid <br /> Tor mo yrer and fa lMAWd as thG VVWk pawn da*W an the frwnt <br /> > e 01,408 <br /> canon, <br /> arsaraa <br /> 00160t I law <br /> esu�rr�r <br />