Laserfiche WebLink
Sin Jonavin County Envrrenmenttal Heelttl Deportmant Unit N Wall Permit At';illcation Supplant nt <br /> JOB ADDRESS: PERMIT SRIF:,. <br /> I f <br /> LICENSED CONTRACTORS DECLARATION TCD, <br /> I <br /> I ttaraby e,Tm that l am scansod under the provisions of Chapter 9 (eomme:npnq with Section 7000)of Div Bion <br /> 3 of the Elus"ns and Professions Cade aid my*Ws*is in full force snd eftet. <br /> i Ucerse# _ �'`� `7 1 -7 -9 ► � Upirsdon Date: 1 - ) - <br /> ! Gate. Q <br /> � siynatxin• <br /> '71de• �Oe(10�� <br /> �j� <br /> Printed nan+e: .. <br /> WORKMW COMPENSATION DECLARAMON <br /> 1 1 hereby awn under Pentdty of Pe►}urY ono of the f krMnq declarations: (CHECK OWE) <br /> I have and*0 maintain a ca"ia to Of oorterrn to saff.inietlrs for workers'con, <br /> by 9aclion 3700 Of the Labor CO*,'htr the Perfamtancs of the work far which tis►wmit�is 4 ed(t r <br /> I have and wet maintain wwksm, instarsnce,as r"ufrad by Section:700 of the Labs Cale, <br /> f*f tits perforn-ance of hr work for vmich this Permit's issued. My workers'ami pensabon ingunuwe <br /> arrier and policy numbers we. <br /> Canter Policy <br /> Number .► p J <br /> I wrtlfy rW in ft performance of fie worts Aar which this psrmit is '33Ued. I ahafl not em ' <br /> any rrtarx 30 as to bacmw eugact to the workira'cont dor any parson In <br /> shoulc beccene subject to the warkera'c�aaroatmatiR4wion Tatars d� 'u'atzd pme that.1 I <br /> Amvmlwrs of Section 3700 of the Labor Code. ! sh ail <br /> f oMwdtt ccaltpf y wtrtt those p nwft m <br /> Prftttaa Name: (e •-.�._.._ <br /> WAJWNG, CAILUM TO OCCURS MICR'C0NiaeN"7VN 40H@MCtE to UIN�W1YFidL,AND>�HAI_L SUBJR�1:T <br /> AN EMPLDV*R-ro CRIMLMN_PO4AL.l1 S AND CIVIL 14WZ Ur TO 10t 04 IS UIR WFUL. NQ[34LALL 3 <br /> IN ADDITION 7p TIIF Gi�!•r OF COM"ENAA'r".WMMT,ATr0Rt'IrY*3 M.,%.ANO CAIMAG S Ai <br /> PROVIDED FOR IN SEGTIM 3704 OF'nK LAMM MM L <br /> 1 / AUTHORIZA770N MDR_�THAN C-87 SIGNING PF.RmIT APPLICATION <br /> 9*nmbxa 041C47 wed strMvaire0 tipregg"p,t,,,), <br /> "a,"adhwtn(print <br /> to plan this 9r J644 rn County well pmt — <br /> AOgtfaa4lcMt on my behair a,rndwvtsnd Whla AvA wMtxF on in v"d for <br /> owe 0)year and Is Nrwit d to om on, pion Orth On the lYoert PqP at this spplloWarL <br /> t <br /> 0-29.02 i AM <br />