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a <br />San Joaquin county �f/eIt p Yysl Per a Arm s <br />JOB ADDR>=SS: PER>3Ni s> <br />LICENSED ,CONTRACTORS DECLARATIONLCI <br />thereby aftkm that i err+ kxnsed uww the provisi" of chapter 9 (colyamooin9 wkh Section 7000) of Dtvwm <br />3 d the t3uswws and Proloseam Code and w ficense is in fa i rce and _ <br />{ Ucense tX. _ 51 tP s s i_t <br />1Ra Conlrad, C�if--n�--�"�� <br />StgrwthNei e.._- Tide: }f i l ° tr <br />{azw <br />prudw ^acne. <br />WOMUMS' COMWENSATION W-CLARAMN <br />thereby affirm under f>eneMy of Woy one of the Mvr M dedarabom (CHECK ONfl <br />I have aro wit manta's+ a cWd6COM d masert to so"n-saue ft, v>rakaV bm. as provided for i <br />1 ~try 5ec6on S7fXl of the Lao Cada. far 1ha }xstr,ra)ance of dee wdk �r +atteh $exs petmn i; hued. <br />iktssua -_ as tegtrred by Se�+x+ 3700 od dee Labrn Cade, <br />t bare and win rrseir>kairt wwlc�w's' �° <br />j far the pedormturs of a VKKk w wuf;h this P 1$ k4„ed. tffy warners' <br />carrier and A6k47 r wooers are: <br />c� ► <br />1 [anter._ C�-�:S_��F'`1 ` �'� vo►tca'ltorebsr. _, �� i C]� �'L-- <br />i <br />I mn,.y that in the perfu'TTance of Itee work for miirch Wo perwW V9 weed, f shag nal empgy any person in <br />any meexwf' so as to became sabred to the worittss' axrtOeseG460re taws of f ati+iM'M and e9(ea heat 41 <br />0.0 b cro a&jd to gee waAcers" _ Paaws_4 d[ Seddon 3700 of the Labor I. I gal <br />� � t } <br />kxnnwtte 1 <br />E)wk tan Date: <br />t'nt� <br />r <br />WARNING: F"-UKE TO S£CLW wUMM14W COi IIC)M COVEpA4M IS UM AWFIA- AND SHALL SUBJECT <br />AM Ejffgj0 fER TO cjawNAL PERAL11E5 AND CMIL FIMES UP TO ONE HUmDp" TOOUSAW DOLLARS . <br />fjjlig,M,),INADDfipMTOTHE COSTOir�ENsAT>�.*ffM T,ATTR=` 'Fes.ANOpAWGESAS <br />PRowf» Fog er sEcTtoe ales or THE LABOR CUM <br />AUT <br />HORIZATION <br />FOR OrM Ry THAN C-67 MNWG PERWT APPLICATION <br />r0, .lc� t ,1 ( yn i� alG�,iae d.rCwr+=�4 rMor.se.N K) <br />h..wy aeaarnee uSi,t enaee <br />I& sign this San Gowdy <br />wait POO 4PS.Gon as fty belaw. t wrdu r+t rtrellew u wiid for <br />oat (1) year Ind is raniead m th• reorir PL- aced oa the none Pw of tlds appbl" n• <br />axs ox t ten _ <br />in 29,02 -mi <br />W22J04 <br />