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l_L GV GVVG VV-JJ r r;U, VMIZ.1.1J1 Vry D"]IVL LIIU IU 17107G01)1)"1 r-.U1 <br /> ' 92/19/2002 16:12 2094 j433 FIFTH FLOM Pg6E 83 <br /> San.iaaquM CmjntyE#mr*nffW,,tg health Departrnent Unit W Wet!Peretz APOP.CliftnSuippitMent, <br /> JOB ADDRESS:—/!5�94�1FT15R r�o P SRdt: <br /> UCENSED CONTRACTORS DECLARATION L� <br /> 1 fwreby affirm&W ram fte neW U d"me pmSians of Chap W 9(ownmormiN vft SCCWn 70Wy of plriaiw <br /> 3 *iii&u'r*w mWsk-sw Codta aW my licenW is in fts fame and edfecL <br /> t,ioesse�_ 63 C,3�� i;3cpiresiion Data: � 3� /O`.� <br /> �y <br /> TAW �, SQ 1 G4"L'I7 rQ r r v- <br /> PrEnted nag. �✓ R r _ /� f — <br /> 4 WORKMS"COMPEN:ATION DE LAMi Iola <br /> " f hepebyaffkM ctrlcf ane d the fn'km <br /> �� try e►8 de>O&VOorss: (Cf1ECIC ALL THAT AiiPl.Y) <br /> 1 hate NXI VA Mai ftk a c&tTx3to of=1SWR to sell-Ihsarnii for wa*ws-ow pauab n.as protrid tvr by <br /> Se,AM 37M af the labor Coft ftrthe peclosttemnae of the work fnt whd this psamit is issued. <br /> I hese Bred will nr **Wn vopim s'oarnpesysstivn Insurance.as required by Section 3-M of the L ebw Code. <br /> 1W the P toe offt WOO fcrre 'hid,tft permA 13 k%Ju& MY wort 0W CMpe.tsvkn Nuumnae. <br /> nut a - , <br /> Carrier. t" �- N j v I Pdicy N unbar c.,<,-3�r o;Z~3 3 g - o,0 <br /> _I C&:Wy ImA In tt�e Peftmenm of the work for which 94S permit is issued.I sfratt not enspiay any pamen in <br /> anY manner so as ID bee me etjed!o Rtae workdeW compen*zgori tams of Czllfoan."a.WW agree lt3ai if 1 <br /> shoal booams WA ed to tate workers' Frvvwom of Sectta)n 37W of the Letbot Code,t sho <br /> fnrtfrmM=t>Qltr wN1 St m pnyAsions_ <br /> Dow <br /> Ptfntad Larne• �-4� <br /> I wAWWQp FAllM Yo S&=W =WBM4T30rsi COV"M IM 4WFUL,AMU SMALL SIUWCcT <br /> AN 6NPLOVE t TO CF&MMA1<P1*MTEB AM CML R NES tiF TO OW HtM Tt;Ol SAAR DOLLLA 5 <br /> 0"116, IN JIDDf"To 1W 0=7 of ENBATiGIt.QST,ATf�ORlte^FE Fe£S.AtD3 D,AMAGM AS <br /> IN SECT"3M OF THE 1J1UM CODE <br /> � (si®eral�ese eR:S1�d wed <br /> to s!�tlts Ssr�.begreTa Carrtgr tai Parrra�t Aopicseiors an Ary>;taRat� i undersbn/frgia man is ra0d to► <br /> o�+e(�3 yar add is iienirad m the pias d:+�ed od Us frart A�dpris ap�icatlel?- <br /> 1f t� <br /> Post-tr Fax Note 476710ate s7�To S� m�`GoJDtrpl Phone 1t ne.Fu# /� . <br /> `; TOTAL P.01 <br /> X33 � <br />