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MaR-07'2003 15:23 FROM:PRECISIO�MPLING 510 237 4�5Y74 T0:5108354355 P.2/2 <br /> rL,v.r, arradr �c:Ge ao'ga���. FiFTd-I �'4�1.I,c <br /> PAZE 02 <br /> San;.loagwn County Eiviironmonw Health Sawices, unit IvwdI Permi3.Appacaticn 31uppiornant <br /> rtf'f'Fi�d �'�spe�� ..S�re•c.sr.-g::�Ric . •l <br /> I 'JOB PERMIT SR . <br /> 6 L10ERSED CONTRACTCIMS DEILARATIO (LM. ) <br /> 1 here0y mei th0ll am Iieensod undertho provisions of Chapter g(commencing.wit"i section 7000)of ivisidn: <br /> 3 of the Susiness.8iid'ProfeWaRs.Code and my license is in full force iand affect, <br /> 'License;#-. Expiration Daft: �,��I <br /> Jv : Con=ctor: <br /> Srgn4turer 91t1e. �9',1`F�JI1'K ,S `K,y/l .aa� <br /> WORKOW COMPENSATION DECLARATION <br /> I hzmby.Ztf.rM vndQr panaity,of p6ir wry ane of the foiiawing declarsWns: (CH=K ALL'NKAT APPLY; <br /> I have and will maintain,a certlticale of consent to self-insure for workers'Compensation, as provit+6d for b'y <br /> Scoon 3700 clihe'Labor Code;for the parfo;marlce of the worst for which this permit is i".U"- <br /> 1 have and will maintain workers'eompensatlon insurance.0S required by Section 3700 of the Labor Code,_ <br /> for AS performance of the work for which this permit is issued. My workers'compensation it swt-6 <br /> carrier`arid po*y numbers am: <br /> Carrier: �'�^'�� /il-t.r` ✓� r! Policy Number: -71 o-7 1-3 35' o l^� <br /> —1 certify that In,lhe°0erfwmanc®of the•work for which-tato permit is imod, 1 811 not employ any porson in <br /> any Biermer so:as to borne subject to the warners'compstiselion laws of Calirlornia, and agree that if 1 <br /> shoUld-become subject tq the workers'compensation provisions of SaWon 3700 of the Labor Code, 1 shall <br /> forthwith =np/6+with th ns provisions. <br /> Oat': �Z/;� Sign®tura: <br /> W,-------- <br /> Printed Nam®: ���`-, ._� —�-------- -- <br /> WARNING PAtLjR f TO SECURE•W0RI®R3'COMPEmSATION COVERAGE43 UNLAWFUL.,AND,SMALL SU,S,I13CT ; <br /> AN laM1eL' wr,�O MiNAL PENALTIES AI�O�C,ML FINES UP TO Ot�ie_HUNDk'Ifi"d'HOU,+�APtt3 DO:�:f�5 = <br /> (;1Q%0d0.I);IN'ADD�ON TOTME COST QR COMPENSATION,iNTEMST,A-MRN&S FEES,At40,DAMAt;ES AS <br /> PROVIDED FQn IN CTIONI 3706 Or-THE LABOR=0L <br /> dsignature WOO IicensW authorlmd roprosantWv4s <br /> hereby®ctehori�(print nom) �� r r�r'" �.�_,� 1 � ��w� . �� '�";,,,..,;-,w'i_�_ •' <br /> j <br /> to sign thr s ,Joelwutl+n C WWI Iom"APvilout an an my bat%oitt. I undamtand'tltis authorlMUM IS-aatld for <br /> E oeee(1)yow awd Is 111"Red to the work plate daeod on tho front paip of this oppligMon. <br /> ��-zoos real • <br /> Z'd 8N05bbd WU12:T1 EO. ze abW <br />