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in Joaquin county E[IthoinneaW Heaft-services, Unit IV WON PermR Stqvplennat <br />JOB ADDRESS: 3,�3, . (0 <br />5' 1- 09EP-6,666 ED. Pauff Sfw:-7f3� <br />UCEMW COM RACTORS DECLARATM M <br />I hereby a1% a, that I am ficensed tmder the provbicm cof Chapter 9 (convnencing w1h Section 7000) Of Dhis" <br />3 of the &nwbesS and Professions Code and fnY I== Is In fig force and effecL <br />License r- 7 06 7 Expialim DMe: 7-11 -2003 <br />Date: . 7 9-&1 woo W#& -A 0 PA I- Lt &r=. <br />cmeadtor <br />SRPMMAM— <br />MAW ranne: <br />VWORKEW COMPEWATM DECLARATION <br />1hereby affin, under pertly of perjury one of the Wowing decbrabom (CHL:CKALL TMT MftY) <br />I haw and vfW nmvtm a cevWicae Of consent 10 seWirmv. e for workers' cw*ensafion. as prwjWd for by. <br />I <br />,er-fion, 3M of "I- L2bw Code, for the pefftWW"M Of Nve WOW for which this POMA is lsste <br />1 and vM8 Worket', compensaWn kWMa,,c,, as Fequied by seci*xk 3700 of the Lajw Code, <br />W the peftwance, cf the woe, for which this, permit is issued. My we cornpectsebm tnstff'a <br />carrier and pofzy rwn*m are: <br />wmre F-oAjb poWwwkw. 002 -02 -SS <br />I cerwy that in the pewfannance of the work for which this penTA is issued, I shad not employ any person in <br />any numner so as to beomme sr bject W the workers' cm"PmSaom lows of CaKo"'t" and <br />WW that if <br />I I ' <br />shoM become subjectW the3700otthe Labor Code, I shz7 <br />fotttrvrih corrwly With atone WOVWOM <br />DaW. -D -IAI-4 — <br />WARMIGG. FARJM TO SECURE VIORKERS'COMPENSAIM COVERAGE IS UNLAVWUL. AM SHALL V-13 i. 'ECT <br />AN EMPWVER'fO CRNMWU- PENALTM AM GW& HIP rOOWNUNWMTNOUSAWW-XLA.RS <br />oiaDAeniNADDnWN'fOTMCOISrFOr-COMMATMMTUaM,ATTORNE"FM%AWDAMAGE-�AS <br />pFM=WMKMSECl SMCWTMLASWCOOF- <br />WC,57 fterned uawriwd mpe-;,mWvej, <br />SpA O—aTsQ PJ <br />to sign *As San joxpzln cawft Well PermkApp&;Am an my behOL IondmaWodthis ftWMIZMbWIsValid for <br />*wCr) rwand iaGmiftd1btore WM pion daWd anew *w* page offft app6caUML <br />2 - CI LL99-tL6-LOL-T pjempooM auReM dLt,:2T 20 Ga Tnr <br />