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t San <br /> Gottstty Etnrircnr> ia1 !>E1t S• '` ----� <br /> I tr�x,UnittY.W,ef3l�rnitf! hart 5ap�rn�rtt - <br /> E <br /> ,iQB ADDRESS: S�S1 4`"-e v�ljoUCl �f:- per: SF3# <br /> 1 <br /> i <br /> LICENSED C01 TRAC TORS DECLAMATION L# GD) <br /> hereby-#Firm trtat'am 11cansed under tt:Q prrviskm of C%ar:ter S( rarr:enarg wjih Section 7C-M c'Civisicr j <br /> 3 W tate 8"ness and Pnofes=ns Cade.and ray!kern a is in'€L-li force and 8f#ec:. <br /> Expration Date: <br /> C1 C1 <br /> Siignaturo: � ride: joWN° <br /> Pdntart rlaette: <br /> i <br /> WORKERS' COMPENSAVON DECLARATION <br /> penalty cf' -t]z►'!+:rx a#the-fdlciri+ag dsclas-at, - (GasEC�G A!_!T}fAT AAPt=Yj - - <br /> 1 have and WD Maintain a cert=fcate Cf consent to self-'r-sure for waftrs'com sai.� n,as <br /> � C prCvlLeG fGr try , <br /> I �ec:i= 3700 of irt$Labor Code.fcr tate pedormance cf the; cec ttrrwttlC^this paotrit is issued. j <br /> V 1 have a.v YAII maintain Workem,cxvenzatkm insurance,as required by Sec'j.^.n 3700 of We t aorr SACC, � <br /> i 'ar the perfornrmnce of the work far,irhich tt:s per=..is jasued- My workers'campersat-ion insurance <br /> carrier and poiiay numbers are: <br /> Carder t i <br /> I ceit-ty that in the perhxrrmrce of th_work for watch tris penrk is issued, I"I.-not employ any penin in <br /> ! <br /> 'any+tanner So as to beccom subjea::to the wdricers'Compeneation lags of Calitvmia. and agree that If 1 ; <br /> ahOuld become sutbi to the worke^s'ccmpensador,previsions cf Sec:ler,3700 orate Labor Code, I shin! <br /> forthwith comply wigh those provislori& <br /> J— <br /> Prig <br /> Name: V t tZ_ <br /> WARNING:FAILURE TO SECURE WORP(I:15'Cr?WENUT1ON COVERAGE IS UNLAWFUL.AND SHALL WBJEC 7 <br /> i AN EMPLOYER TO CRIAMJA=PENALTIE. ANO CML HIES UP TO ONE HOunRED TmoUSAND DOLLARS <br /> (#t00,000.),IN AM7101d TO THE COIV C11 CCOWENSATAON,INTEREST.ATTORNEY'S FESS,AND CAMAGES As <br /> l <br /> PRO" C.0 MR IN SECTION=4 OF Tilt:LABOR LODE <br /> C4A {C-S7 iicacraed,oufhoririd rapnaerriative),herrhy <br /> 1 - <br /> to sign this San.Jamluin Courtly Waal Penrit APAlicaftn on my b aiwi. 1 undoextond tnie nuthortzadon is v0d kr I <br /> one tt ear aPd ia ttmdWd to the vmrk ptann bated an wo nand of this ticailors, r <br />