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Ar 000 , <br /> aF ay► ?oriietraLitiatffi> ry; = Fref#i3r.�N _ pE ' ft�rr`e . ' I <br /> AIJ TOA' r ...q :N71 .tiff+ •r. . :::::'���:' ,'yE.,� <br /> :-.....�,.�....•� -.-..-.w�....�::�... '��'��'- _ ;v=a--r-=— <br /> LICENSED CONTRACTORS DECLA A71ON LCQ <br /> 'I¢rebV @M1tm that i am JkTrWad under the provtSions of Chapter 9(camrmncing with tedion 7000)of Divisian <br /> of Gee SWn6ss and Profession&Code and my license is in full fp=and effiwl <br /> -710 dire -7 f <br /> Date, rrtrraotnr L.LrI N(I. i( <br /> Fftic: Ipi4lD/y 5 n7�rUAlz- ! <br /> i <br /> WORKERS' COMPENSATION DECLARATION <br /> F :herfby a"under penaW cf perjury one of the following declarations_ iCMECK ALL THAT APPLY) <br /> I Neva and will lx+teintaln a aerMicm of mnsent W self4neure for wel'kers'corn nB�On,as provided fQr by i <br /> • .SeMon 3704 at tie Loor Code,Tor the perfor um=of ft work TQr which this�t is issued. <br /> !have and will maintain Worke ' wrnpensafion insurance,as ra�gttired by 804av 3700 of the Labor Code, <br /> fr ,r the performance of the work for which this perml is issued. My work ws'Compensaf om Insurance <br /> pier and poky numbars;ne_ ; <br /> Carrierr > vN Po1ky Nuenli". 3 i <br /> l car*Owd M the perftx=nCs of the worx for which this perm is Issumd.t shell not employ any person in f <br /> any manner so as to be=rne subject to fie workers'amp Son laws of Cairforni% and agree that if 1 <br /> should became subjectto tl*workers`=mpensMon prMisions of 3ectlw 3100 of the Labor Coda, i Shall <br /> fia&with uonvo with tficse txwislons. <br /> Printed Name. <br /> f <br /> WAMMG..FM.METOSECIjREWQRKFfW-COMPW"'nONOOVriFtA 19 UNLAWFUL,AND SHALL,SUBJECT <br /> AN irlltPr,OYP A M CFi1f+PMAL pERALTIES AND CJ%L F NES UP TO ON6 hlliNIMM THOUSAM0 DOLLARS <br /> i (3rlao,OW0 J IN AIMMON TO THP"COST OF COMPOWA'f M,IHM-REST,ATTORNEV—S rWA AND OAaiAM AS k <br /> pROMOgD port ip 3a=0N ems OP Y14E LAk'l R Com. I <br /> (C4rf iicera !�lerltrori�ed ar + ]� by <br /> to sign V&am.ioaquirt Caunty Wep Parctfit Applicaf+o"on my behalt. i understand tis auifharizatuon is valid for � <br /> .° or a{q} ear and is lirnttad!0 the work plan dam an 2M front AMMW ar tl%%v0pbabom <br /> r i 1 LJ� <br />