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Regived Fax: .09124./09 03:1.9,P �Fax Ststia: ,All Yell -Andonent 04 <br /> -son.iosquin County,.EnvironMental Health Dep rtmen't Vnit-(V Well Perch Appllcatlon$uppf mental, <br /> JOB af3flREss: . ,��, /-� � . <br /> Z <br /> LIGENSED'CONTRACT'ORS DEC LARAT10N.: LCD) <br /> 1 fw+ .li� u�..iII tiE i u. i Iha..ia�..il NKlvi IIw NIV•IJIaiiJ a/r'Ole;lslca O�saaniii�v�iirlf���.ttl�w"Io4l1V+.-Y.4QO�Vr <br /> Division.3 of the Dusinoss and Profpssiops Code and my ticAnse:is in full force 'arid effect. <br /> License , tw i Date ',.1 Qr l <br /> Dale: 72 <br /> Signattr <br /> -_ <br /> Print Name: -_y i-kc _ <br /> ifY IRKER'S COMPENSAT.IOIi DECLARATION <br /> I hereby Arm under penalty of perjuiy or►aof'he folipwirlg<:t6clarationsi(chA k brie) <br /> I have and wlll maintain a certIficafe of consent to self-insure for workers'campehsationr,as. <br /> Provided for by sedion 3700 of the,tabor Code,for.toe mdormance of the-,Wor.k for which this. <br /> permit is issued: T <br /> i havenrf will.ma}ntaln wnrkirmnsntinn iso=rarzcs;ar raquired by Sectlbn 3T.tfo of tfi6 <br /> Labor Code,for the performance-af.lhe Work for whl 4.hffils permit'is issued. MY."Watket.e <br /> cornpenwjon insurarrce.carder and.policy'numbers are' <br /> 'I certify that in the perf6rmano6 of the wor:ff for which this pert77it is issued I shall not'e�Iplay dhy <br /> person In any mariner so as.to become subject to.th-a workors'compensation law of California, Gild'. <br /> agree#hat if t should becpme subject toi..w6 Iters'co.nponsation:provisions of Se0160.3700 of:the; <br /> Labor Code, I sballl fiorthwith comply With thnse`prov!s16ns, <br /> PefM Name: <br /> WARNING.TMUH[TO BECur2 V!i)R1Cf RS'CdMP99.%AtibM e0Vhf'tA4E 15 UNLAWFUL,AND-5HAU:600JEGT AN.' 'LOPE- TO_ <br /> opisANAt•PewALnEs AND CIVILF114ES UP10•$100;900;INADr 11 ON1 THE Cos'0E-d0MPEN3A110U'11!-MAr;6T <br /> ATTORNEY1 fFESA ANDbAMACAS'AS-PROHIPER FOR IN SEC ON 3105 OF THE LASgft CODE. <br /> AUTHORIZAT11 N FC1R TITER THAN C-57SIGNING PERK IT APPLICAno <br /> t, ! Ainnaturit M,C.V icensed autfiorl7..ed eepresbhtative). <br /> hereby authorize(Orin amb) s� <br /> sign this Sart Josquin Wlr tl Pstmit Applka P iifahaif. .tvndoref3rid fhijt aUtholSEat tsri.,ta vaild <br /> for one year and is lirnited'a the work plan dated ort the.frotti;'page of#his lgpplfcatidti. <br /> i�(32b04 1 t+SgT t5+.1CPE,73.�f'/.PR' <br />