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Sun Josgnin county Enuieonmem*t Mearm Oopinn%pnt Unit N WPtt Permit Applicawn Supplement <br /> JCB ADDRESS_ 54o u. PEMT SR# <br /> LICENSED CONTRACTORS DECLARATIONL� CDS <br /> thereby affirm ftt i em Mcenaao under ttw provisionB of Cttoptev 9(cornmQmkV Mh Section 10W)of 01vlelon <br /> 3 of thv Brmir►ns bM ProkiMlons CWe and my trcerrss is In 1LM k We turd e*a <br /> l icrxT�e �p nl Expiration Daae: <br /> Pr;nted naaw. ►r1,t l;L: � – <br /> 1►Y(RKERS'COMPENSA77 M OEGLARATION <br /> I hereby afiCirfn under puilty of pa junp Dnp of tho foltm"dcea litIO i,' (CHECK ONE <br /> I have and vAll rrrarntatrr n umlific0o aF consent to$etf-insUrP ror workers amrpCivs" 5M.sty pra%Mtad far <br /> by Seafai 3700 of the t aper Code,for the perrorM*nW at enc wai[rah which tN't PUM111 r`issued. <br /> I have and val mair�war'vt %,cmvenv4tion insurarrcc,as r5qukw by Sectla+3700 of the L-ab ar code. <br /> for the perka"atsce Of tris VJOM for which lr*,-permit is issued. My workers'compcnsstton inevrarroe <br /> cwiiw rmd policy numbers are: <br /> �y Piurntrer t L)'Y_02—& <br /> I certify Matin flit,pestonnarboe of the wwk for which his permit is owed.1 shall not cerOGY"PCM4)M in <br /> any MM~!go os to t@corftd sub}eo to the workrxu'MMgMrrsoM taws Of CZIMOfY&arta agreo thalt 111 <br /> should broom sba rd to:e vmrkme compenrabw prvvWma of Secim VOO Ut ttr4 labor Coda.1:halt <br /> 40*%%%V7 c"noy wNh ttroee prnvisio+ss. — <br /> Exptrattan t7atw: �� _ l igrtatuta: /��- <br /> I <br /> "nted MAIM: (� <br /> rtrA +m1G:rAiWIM To s[WIM tar4taKEW CON ATION G t;is UNLAVO M,AM SHALL SUBJECT <br /> At EttMOYM TO Cir_PEwu,nF.3 AMD CRW t UP TO ONE HUNDRED TWOUSPOO DOLLMS <br /> 0,100,WCJ.tin AQDnMN TO TW COST or CONW01ssbYMK WMRMT.AT10#7110-3 r'r M Arte IbAMAGES AS <br /> P WMDED FOR IN SECY#O>•t TTM or-THE-LABOR CODE. <br /> AUTHDRt7A11 f0N11 POFZ OTHER THAN C-57 SIGNING PERMIT APPMATI N <br /> � t- 'L�/� � siarritwd v[Cd7 t1t:i11R4a Av1ND►izFd RP*�■�bt+rti}� <br /> here"auawrtm(pea"110M+*I C-,%re K L 9`%td"r �IwWw%Mtxnd <br /> c <br /> tr►sir this San Jgaqurn Cauntf'Wen Permlt ApprteaNW art mthis authwixa!!on is rZltd tar <br /> om tT)year"it Nrnewd to tiro work Phan WtW on tM fmnt Pry Of'tt1is Wfics&& + <br /> WD 29-02,001 <br /> 6.TL04 <br />