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7-28-1996 11 :27AM FROM P. 2 <br /> 4weu-cvu l !'trill uy.l ell llc , iN4, - i PX NO. Mb 8h,.0360 P. 02/03 <br /> 04-20-2013! 03.,40PM FROM TO 13156531868 P.03 . <br /> 8ratz ivaqu-in County Ertlrironmerltol Health&vrvicea,;mik tY Will Ptrmit ApPHOW9n Supple mernt <br /> aOBADDRESS: FF��t✓sCr4v�,rJu� ,4�,p Pr <br /> RMIY SRS: <br /> �51��G4'S rL6AtJrS r�c.ICt�J,t� <br /> UCENSEo.CONTRACTORS DECLARATION (LCo) <br /> I tweby affirm that t urn•hearted under thb provlOonc of ChijAW 6(COMMtming with Section 7000)of Division <br /> 3 of the Swine/sspanti Prlofotiiions Code and my license is in full fo=and effect, <br /> Date: ~�� `U. /Gonvactor: JEI S 14 AJ V <br /> Signature'---1- �+�� Ua.,-fZ��e� <br /> printed name: - <br /> WORKERS'COMPENSATION DECLARATION <br /> t haratyy arM+rm utrGer.penalty of penury one of the tollowirg dedRrptions: (CHECK ALL.THAI'APPLY) <br /> t have and will malntatn a wrtifscatO or cO nS"A tO 9&-in3um for work--M'cer,spsnsxtl0n.or,Mv4ed for by <br /> Sftkn$700 of thrs Lator Code,for the performance of the work for w ich this pw"t is issued. <br /> E —ell- e and wlp rrrafntaln Workwif com"naation insurance,as requ;rvd by So4on 3100 of the labor Cade. <br /> for the performance►of the work kyr whkh this patmlt is lsstred, W workers'compent orlon frlst,rrance <br /> earwr ttnd policy nun-bets are. <br /> Carrier: A Policy Number: <br /> I oWtIfy that to the parfori wrrt of the work for which this permit is Issued,I shalt not employ any ptrsorr in <br /> any manner sa as to btcome subject to the workets'conn "axon laves of C Igornia,and agtr&e thot tf i <br /> show t�ecansv su610ct to the worr<ere Cornpt'rr5e60m Oroviaiorns of$octlon WOO of the tabor Ovde, I Mall <br /> forthwith Comply with thosa gmyWorm <br /> • Oafe: ,,;�,�,�,_,$l�lrrltilrl�' �f��� <br /> PrIMWName: <br /> 'WARtVAIC*1 FAILURE TO GCURE WOMERS•C010ENSAIiON COVEM69, IS UNLAWFUL,ANO SKAL.L SUWICT <br /> AN OWLQYFA TO CRftlf ML PENAL "AND CML FINES VP TO ONE 7HUNQRlriD T"USAND DOL4ARS <br /> iis000co.;: <br /> IN ADDITION.TO THE COSrOF CotAPENUTM,IIIREST►ATTORNEY's FM,AND DAMAGrSS As <br /> PROYIR sEP FOR IN'SE".ON 3706 Or TW LAbOl t CODE <br /> Ale _ ._{Gb7 Anent attti+or tfd roprsc@VlatJwh hereby <br /> authorize �/c''t/1IJ <br /> to rlSh this Aon Jomin County VYv1i P4?mtt ApplinWrt on ray behalf. I und�tind LNO awthorkaftft 1*valid for <br /> one f Y-4arand id pttrtted to efre work tan dated on the front ow of d*a cxtior, <br /> i <br /> r <br />