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.V4lGo/CG1C! 1L:GG LCl'747'.7lfb4 UtreW UNLLLiNU HAUL bl <br /> to <br /> spin Joaquin CO"ErIvironrmntat artm"t Unit IV VVWl Parma Application Supptirnental. <br /> Jals ADDRESS: `' ! G!/. Pelairr SR 0 <br /> LICENSED CONTPACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the Provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code Orad my license is in full force and <br /> License it -- E Date: <br /> Date: o� U Contractor L . •�J'I(1 �1 <br /> St$nature: <br /> Tide: <br /> Print Name:260f- <br /> , - '! <br /> t .. <br /> _ _ __� WC1FfKEfiZ's CbtiAPENSA - DECLARATION --f-- - - <br /> I hereby affirm under penalty of perjUry one of the following declarations:(cheek one) <br /> I have SLnd will maiftin a certificate of consent to sett insure for workars'ca <br /> Provided for by sedon 3700 of the labor Code, for the rrepensativn,as <br /> permit is issued- Performance of the work for which this <br /> !have and will maintain workers'oompensation insurance,as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit Is Issued. My workers' <br /> compensation:insuranKM carne and policy numbers we: <br /> Carrier: <br /> Policy Number, 'r <br /> JV tfa� L"' r..✓ � <br /> I certify that in the performance of the work for which this permit is issued, I shalt no;employ any <br /> person in any manner so as to become subject to the workers'compensation law of California,and <br /> agree that if I should beeortte subject to workers`compensation provisos of Section 3700 of the <br /> Labor Code.I shall forthwith comply With those prow . ns. <br /> Exp. Data: C5 I <br /> Signature- <br /> Print <br /> Print Name• f?Dbb ' V C-. <br /> wAJgI1NG:P -k"M TO Wv0%RE WOWEW COMPEN$ATHM CWORACE is UNLAWFUL,AND$kALL aUaJJE=AN EWLOYr=R To <br /> CRrYtNAt PWAt TJ1F8 AND txiyfL FW3 Ur T4 PQ0 ,pDp,IN JeOAITOM TO TN_E CO$T OF COWEIP_A7" IKT�ItfST,- - <br /> ATTCRIlEY'ti rtes. <br /> AND DAMACiEs A.i PrtQV-jD 1 FDR I"0961iM Mi CF TliE LABOit c0DL _ <br /> i, <br /> ! R OTHER THAN C.67 SIGNING PERMIT APPLICATION <br /> ( ig : re of C-57 licensed au <br /> hereby authorJU(print narner) <br /> Sig n this Slut Joaquin oo#1r1ty M(�lt Permit .too <br /> Amllca On my behalf. i understand oft Is valid <br /> for ane year and is runibed to the work pian dated on the front page of this appllcaUon. <br /> �Ho zea, ,liar <br />