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ryuuziu0z <br /> San aqJnu(n Coy tvirotw Hcaltrl Dopaltmonf unit Il 41 Prrmit ApPp�atio� '::pprr•, n, i <br /> - - untnnF wa ,X1' ®o � <br /> JOB ADQR-8s S W . V(���c r — tzEl�IVI('f SR(7; .- <br /> N �\4D 4 <br /> LIGENSED 0NTRACTOR,S DECLARATION (LCD <br /> I helctry affirmthat I am IiCMtsed u dtv-thc+provisielrs aF tautplrr9(conmrndng wife`;flcr n 7000)of Ufvtspn <br /> of the UusG�e7<•s and Nro{P�essi[ons ode and n)y licc-jrn is inti full face and.411,11c n <br /> License 8: t 1 — Torr nate: <br /> Prtrtted.DarFrc: V, I Uri — — — <br /> WORI UEt 'COMPENSATE 4ECLARA-nQN <br /> I,wrahy a)firm undo(renally ofpedj A,.y an4 o:the fogow(ng tiedamtions: {GIIECK ONE) <br /> r lave and will maintain a coilftutP of W nsex)I tv solf-insula ex walkers'compensation,ae'pmxi�jed for <br /> by S"on 3700 of fhe Labur C do, for the purf6niwnue of the work forwh(ds this portrait is(rsued. <br /> 1 have and will maintain Worker canpensatior)inaurmce,as mtuired by Scotlen 3700 of the Labor Code, <br /> for the pa><fo<t o ,ofthework which this permit is issuod. My worker;compensation insurahcc <br /> canlar and . lay n am. <br /> Ca"Or. CCJ ._ Policy Number:1LY./"I <br /> I oerify,that in ft porfantlanc;P f the work lar whidi this pkItn(t is issued,I shall not employ any person in <br /> 5r y nlannerso a,to became sr )ect tri the w0rkels'.cornpensa4(on taws of CQ;db nia,and agree trial i1 I <br /> should become subjo to tha rkers'rwmpefssa 'un provisions of5k:cti n 3700 of thr.Labor Code, I t;I%RK <br /> forthwith complywith those pro ns <br /> ste7 <br /> Date:... S nature: <br /> Print Name: <br /> 'WARNRiG:FAILURE TO SL'CURE A' KGRS'CoMPENSAiION cOVI;RAOE IS LINLAWI'UL,AAD 314ALL Su&if:C <br /> AN EMPLOYER TO CRIMINAL PENAL. 4125 AND CIVIL FN7FS Up TO ONE HUNDRED THOUSAND DOLLARS <br /> (St 00,000:),IN ADDfr iOW TO THE CO T OF COMPENSATION,INTEREST,AtTORNIEVS I'EES,AND DAIPAGEB AB <br /> PROVIDED FM IN SEC OW 97060E HE L.A@'OR CODE. <br /> T40RI7AT`!:' -F - RUM114AN C•67 SIGNffJG PERMIT T APPUCATION I <br /> (sipnotore ofC57 liranyud authgri:mr mprn:.encaN we), <br /> hnryLry authurizr(print name), <br /> •le,r.yjn Llti•i q:•:j::M'ILIh C'M{Qr�•VV.•ri •urfnli AF`1+11rZP:^•1,CI•ra!' :.fti,21? il'IJOW:iatt.i fid:<niaSt CGI•ntlo.: n-+•:I!•+s:+• � <br /> is 't.nr Pe r::tty w•.i tai?,:'div.:t,i:i,' 71„ie!,v,, .. 1.•a+ '•rJp i+Lt..na <br />