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Oct-08-01 12 : 37P 0 - P . 04 <br /> F17:F <br /> quin County Envirotw WnW Health Swvl,..,U,*IV tn.Ii Pwmit <br /> tAsk r s+�1K#trP �� Hare f twOn s�P,z.�m*nt <br /> ES$. �-� yr99Sao V, 637s o C, .� PERMiT $R#: Z <br /> LICENSED CONTRACTORS DECLARATION L D <br /> I haroby orm ow I ern kowtow under the prvww ns of Ctteptar 9(Comm&n ing with Section 7400)of l]Ivlsion <br /> 9 of 00 Buelneaa OW Praftmions Coda and my Hawwo is in Full k"and effect. <br /> t�rt,e '2 (ArA?t r.Expiration Date. <br /> Prinbd"arm, h�� r. /p•,•. .. .� <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under peru ty of WurY one of the f0llOw1rp deotarations: (CHECK ALL THAT APPLY) <br /> 1 hav0 ON will rftkltah a aerlMlcata of consent to self4mm re fbr workers'comperteabon,as provided for by <br /> Seofon amo of"t*bW 00"-for the performartca of the work for which thk permit is Issued. <br /> 4KI have and wail maintain wwkwW corn4o aelion insurance,as r"uksd by Section 9700 of the Labor Code, <br /> for"Perfo marme of t#o work for whloh'h's Pwmk is iatwad. My wvricers'oomperss Wn Insunv= <br /> Carrier and policy nLwnb rs orf*: <br /> Carrlar: Policy Number: <br /> I Carsay that in ate performemoa of ate work for which this permit is tsWW.1 shorn not employ any Person In <br /> wry nt mnw so as to b000nte tlugjad to the workerv'coffqwwAWW laws of Calftnla,and agree&bait P I <br /> *WM become subject>ho ftwmkw2 Compensation preia www of 9eotion 3700 of the Labor Cock 1&W1b*wtth ComPlywith avow praAaions. <br /> 1]a>Sa: �D� Signatme, <br /> Pdr4od Narrw. <br /> WARNING:Fwtt- W TO SECURE WORKERW COMt' MATION COV ERAW IS UNtAWFUt,AND SHALL au13,IaCT <br /> AN CNIM.OYFA TO CRiWHAL PEdALTM3 AND CML FIM Up TO ONE HUNDRED THOUSAND DOLLARS <br /> Is�aeAAA t INAD13(7 1 TO THU GW or COMPE SAVION.INTEREST,ATTORNEM FEES.AND tKWWti As <br /> MiOtiIDED FOR IN SECTION vus OF THE LABOR COOS, <br /> r <br /> �"T llos WWd sutharLsed hprr <br /> aulharl�. aourrtafty*},hwshy <br /> to s4"tltla Barr JO"ln County Wee Pan"k App kwon on my behalf. 1 uedsrstand thta 80110ft4tiOn k vmlld to <br /> &W(f)t'uwand 1a prrdtod to thtworlc plan dated an the front M9 of thl,sppliation. <br /> a-17 <br /> ziz abed : l9�zL Go-B-�.�p :ZOEO ElE 5Z6 f .�ui `6uT sa <br /> 1 V 6UTTTTuO 669i0 :A9 lugs <br />