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1804/2001 14:44 2e94671119 AGE STOCKTON PACE 02/92 <br /> San Joaquin Cam"F-AWIn AMOnhl 160M Samkm%Unit!V WGII POrrrtR A;0wfftUM MAESPI <br /> JOB ADDRIESS: �. 1 � VR. __ PiRly!IT <br /> Sbr 11-rl-o^ CA <br /> MIENSED CONTRA►CTORB'DECL►RA71ON CD <br /> I heoeW aferm that I am f o, ad tmdw fie pe,a Morn of CrtrEPW 8(00nwish Section 7M)of DlAllon <br /> 3 of the Husine*aW PrefrlWa m Cads and my ltraenae is in full hxen and COWL, <br /> Lroecaac S: E�tpirer©elac J _ <br /> Date: V.1, 460 t COADIA20r <br /> 8lgrrrwhrno� _'"""� T a. <br /> -� - <br /> Prtrtbed nautte: <br /> WO RS'COMPENSAMON DECLARA"1tt M <br /> I hereby a mn under penally of perjury one of iiia Mllw*"dedarsUtOMls: (CHECK ALL THATAPPLYy <br /> t hxa a and will maint6rin a 60i at aarrseid to self-ins;"For vwarkars'comperwagon,as pr' Mcd forby <br /> 5ecltnn 3700 of the Labor Cade,for the performame of the work fpr whiatl this perm$is issuel <br /> I have and wn mahtWr vw dorm'Gompen=ffon insuranw.as regulmd by Section 3700 of the tabor Code, <br /> for the perfb m nor of the work for which tills permit is issued_ My w orkers'cctr'tYparoagorr au urance <br /> carrier and policy numbers arm <br /> .— <br /> carrier CILA Policy Nurt*er:, R,J L-.. ��� n <br /> I aarft that in iiia pefti,tance>7f fm wark Wimh6ch this permit is issued, I$hog rmt erimptay my ism In <br /> any manner ee as ho became subject In the rworimW eompenzedon tWOO of Califs nhk and agreO OW it I <br /> should bev=ms subject to the workers'c>mpeasedon prmialum of 36OWn 37170 ci the LOW Code,I shell <br /> kirtmilh comply wRh them proviA mm <br /> �� l� tb Siarrabure: - <br /> lFrfrnied Name: <br /> wAR00Dma,FAiwRE YO aEcunE WCWOMNB'Cti>lipOLSATION ODVERAGE lM UM A11YRX,ANI 3UBJWr <br /> AN ESR TO CRUMAL PENALTEFS AND Ciir1L RMIE'S UP TO ONE NUI00RUD THOUSNO SICLLAl%$ <br /> (#100.0004 IN Ammom TO TNB COST(w TSt7N,Ill ATMAIEY'S FUS,AHD RAMIAMS AS <br /> PROMM FOR IN SIiEC M 3700 OF THE L ABOR 0 <br /> ��'� 4 iC�67,Barrserrd aullnartr�:•pra�tbtlw�.hw+eby . . <br /> aeerttr e - <br /> 00 WO this tliarrn J044913 Caunty Wag Perwnit Apptle;MM an my bOndL I undwwWd MIS arslh4rnor 0 1 b ltaitd for <br /> { arw(1)VErr nerd Is Ihniba+d to the work pMn drtbd im tiro*imt purr of Idris sppikwfore. " <br /> It-li-'1001 ME <br /> C/O 06ed !L4:S� 10-V;3-130 `i;t)£0 E4, 'Sa6 `'oul `buTlsai V 6uTTITJO 860JO :49 IuOS <br />