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i <br /> 3„n Jcaquin County lnvtroamental Health Servs as,Un' 3i/' you PeimliA <br /> KERMIT 8R#-. - <br /> LICENSED CONTRACTORS DECLARATION ION LCC a <br /> L <br /> 1 neratry zff=Mat i am t=nwd under lhwt pmvislers of C.'woar 9{comme=inQ with semi 7w)at Diyi5jon <br /> 3 of tt-.SualrQ s aid Pmfussivns Coda and my dew=la in futl Intue ant#effea <br /> cam. <br /> ._ <br /> We.- <br /> Printed narna: <br /> r <br /> WORKERT rOMPENS 79fl1+1 GLAEi . t lel <br /> i]yeCB�y affr trr;d�r pe7►�lty of P # r`!ons of allvwirtg de�2 tiarls- (04EC�SK ALL i'6#AT APPLY <br /> I have ar.d wili niWntain a=ullf mte of narrsant to sslknour-aer war'mvz'=ihpan ion.as�woYlded W by <br /> ! <br /> 5a6cri 3700 of rho l abar Cade,for the pWcnnar1Cff of tm vW urk for Wirtir h tills mit is Limed. <br /> t t have and !Affil rrlaMtain+erot*wz compensattan insurance,as ranured by a�iion 3,700 of the Labor rK}f°. <br /> for the pertbri nca d dw wurk for vdd d't;tris permit is Issuad. Atly workers'crv�wm2tion}nsumrse <br /> carrier and palicy rlrm4lnem t <br /> s I terlify mat in the perf=enca cif?Fra work for which Vus Parr lit is J$-5Qed,.t�aEi fat s�rc�[py�y p$rsi�n in <br /> gny rnan>'ler so as to eecG a 15clt3=t to tie W0rKe91'=np art JOIAM of�s farrlia,and agree that W I <br /> should became subjad to lba warkere=parraiion PtMdsia of Suckm 3700 of Me gator Craide,f 210 <br /> lorlhwilh ODr PIY V*h th=3 pmvislom. <br /> { <br /> Frint,ed Na3t�t i <br /> frf <br /> 40--)- <br /> WARNING-FAILURE To 5MURE WOitMf V CQt1AF>EIM SAMOlt ee Is UNL�WFVI-AND SK0.L.L SUS.1F.C.T, f <br /> AN EAVLDYER TO CRMMftFEWXT=Alfm CML PD&S UP YO C WE PIUNDR90IMOUSAND DOLLARS <br /> {S 100,0ft} IN ADDITION TO M COST OF COWI VS11 iM,INMR ST,A ITTOMeft r0g,AND]DAMAGES AS k <br /> Ptl0 EEM FOR IN SECTION 3769 OF`HE LABOR COVE. <br /> to 31gn rhes San joav»d cQuAty wan t'ertrdtA Wl=t10n an Jay Whair, t understand this xathertrat7pn is v&%f Orn <br /> arra fl)Y%V=d Is amumd to tlta work plan Wad an ft!rant pap of thka aRp:leaSa6 <br /> s•t7.�#lan t Mi <br />