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JANI�IAO <br />dCtrniirli< 1,irllt Rf <br />ijealth pep <br />t verrr►lication �S "e1nent <br />it App <br />Sandoagvin Co 'y �r,vrranrn d ud, PFRMIT <br />+Ira qp M >ES <br />SR#; 052 , 6_� <br />DECD► T1+DN SCD <br />I^rCEMSEp CONTRACTORS740Q) of Division <br />ter 9 (commencing with Section <br />under the provisions of Chap <br />f r+> yafFirm that 1 am li fess ons 6011 and MY license is in full Faroe a�nd��eff I <br />31t%Busrness and pro Expiration Date'. _sas <br />�t Cantr2Ctor� �:. �� <br />Mllnarna�TIQI`I <br />WQItKE�S' CQMQENSATIQ'N lSEGLA� I� ONE) CWEC <br />Of erjury one Of the �ollowinq declarations: ( rodded for <br />' affirrn under penalty p enpermit s i p <br />of consent to self -insure far workers' comp, permit is issued. <br />LOW Code, for the Perirmance of the work for whici this P the Labor Code, <br />+r® and will maintain a e cats for <br />Section 3700 o'F <br />It io�eetion X704 of the Le as required by <br />intain workers' comp <br />ensatioll I is issued, MY workers' 0ornparnsstion insurance <br />)te Awe <br />and will ma the work for which this Permit <br />performan( of <br />Mier and policy numbers ate' <br />policy NumbeC: ��--' arson in <br />{ shall not employ any ie <br />'Stier: rrnit is issued, Californta, and agree that if l <br />of the work for which tp nsation laws of I shall <br />"aIfy that in the performance workers' on X700 of the labor Code, <br />become subjG;& toCthc- nsation provie,ions of Seco <br />;y manner so as bject to the workers -� - <br />*uld becarn i 1 with those provisions. <br />h COMP Y <br />a - Signature'_— <br />r -- <br />Printpd Marne", p140 SHALL. SU ECS <br />CI�VERAGE IS UTILAHQLISAIdCJ DQLU\ft5 <br />aMpENT�gN ONE HU'NDR>~17 ES, AND DAMAGES �. <br />E Ip SF -CURE 1M1fQ4xKERS� CCIVIL FINES 1!p TO ONE <br />AT-r'a�NEVS 1=E <br />1G' FAILLlR PENAL rlr-S AND ON, {ia <br />OY� TO CRIMInAI COMP Civ <br />IN AbDITION TO 'TRE OST <br />F THE LABOR EMIT ,A�PPLICA`T JN <br />IoN 3706 C-57 SIGNING PF <br />p FDR IN �i8� � TNAN <br />GIiH r,esentativei, <br />A I I-I.140RIZATION P _ J Iican�sed ��thoriy�'a fe>a <br />afCr67 <br />behalf. t und£rstand autha <br />r'�"tion is Va lild for I <br />0�authsr�,O-ame) <br />licatiar, on m� <br />a uisi rountY Wull permit APp of t9�iis aAPlic'r'o;'. <br />4thi$ San ja c Ian dated on the front P-10" <br />4 year and Is tirnited to he,,,,,P <br />A, jz-lao 0tit 1-nir11i i <br />