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t i -Le� :•alri r•nui� r <br /> { � QHS_ ttYIY �#7M1Ao i Ailt 0*Partme at Unit FV.W0 PiwMit A,ppkalkin1upplavie t <br /> j <br /> JOGADDRESS; PEROT :Ski#: <br /> 3 <br /> LICENSED-CONTRACTORS DECLARATIONL( W . <br /> I hereby affirm that!am licensed under the provisions of Chapwr 9(.^,orrlmenczng with SectiW 7000)of Division <br /> 3 Ofthg 8lrsiness anti Profeasions Code.and my 6csr1se i8 in tail fame i nd effect <br /> . ., Expiration Date: <br /> Dater <br /> Si lige: ' <br /> 1l OR1 EFW COMPEN Ai,'TION DECLARATION fY� <br /> rl hereby affirm under penalty of p eocary one of tt'se fallowing oeciarations: (CHECK ALL THAT APPLY) <br /> have and will maintain a cern hate of cns*nt to satf-intaro fi5r.workgr5'aampensatan,.as prcv�Wad for py. <br /> --.�5Qcti¢n 3706 of the labor Code,tot thO Worrmnee of the work for whioh this permit is is sued. <br /> l hjva a%tMP maintain worfterc'aompw setinn insurav&,as mgLeited by$=bon 3700 of the Labor Goda. } <br /> for this <br /> per'forrrgknCe of1t,q walk for'whith.this permrt E5 issued. My w�iriters'CorBi�it]S'7tti�n.irs$ur3t�re <br /> rWrler artd p licy umbers re, <br /> carrier.. Party Numbor: <br /> _1.orrrtify thatin the parfcxmsnce of the,rncrk for Which'0116 P&ym..t is iesuad, J sails not emoloy any person in <br /> any m2nnor so 26 to Oecora a subject ta:$fsa.workers`tcrtlpers5ilttoza laws of Cafftmia,and agree that if 1 I <br /> af'Ould become subtati:.to the wokers'cornpemation ptavWonz 7f motion 3700 otthe.Labor Code, 1 shall 1 <br /> I forthwith comply wr ttthoB r praviajons, - <br /> Date, o;2 <br /> t Printed Namw c ' <br /> 1 wAli*i►Cs;FAiLURE TO Bt=GtJRE WORKEnICOMPENSATION WvEgAGe:JS tjN AwFuL,ANo SHALL SUFW,ECT <br /> I <br /> Ail PWLOYER TO Cftll4tlN*L PENALTIES AND CIML FINES.UP TO 011* t1INDRED 7 HOUSMD.DOLL.Ais <br /> dp,9bb}„ <br /> IN t A00tTION 7d TW C6ST OF C04VENSATJ0*,;NTE-AE&i ArrO NEri;FEts,AMID OAMAISE AS <br /> i PRO'VLMD POR IN SECT:ON 3706 Or-J'."G LA#DR COW. <br /> -� �Wmfv auti 1' iizc tprsi nt v$tna, W I <br /> to 04n til%Un J'"quin Cao"ty Wall Atm*t A ic"Orl alt valid f <br /> � my t�rnif !lrsslarst�nd thit.a�+rhari�figr�in y�tid for <br /> yaor and is tiMftd to the work plan dated an the front pag of#his 2ppuration. <br /> Gd WctLZ:I0 5022 t'ti q3 j. MG aLQ GW -inti 3N0"d , sF 1 Lucy n,,010.40 L7t7b; <br />