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IA@3 <br /> tiotr JOMP ll CCW*Y ltity—M*O ntO MDa Ma Sn rloea.UeS N%VOU Perrnit Appiention Su pplsn2ent <br /> JOB ADDRESS c 6, &c- it PERMIT SRW <br /> SENSED CONTRACTORS DECLARA77ioN (LCD <br /> I hersrby aflr.n that i am Warmed under the pnwisions of Chapter 9(cummenc kV with Seckm 7008)of Di hOon <br /> 3 of the t3us*MM and Profession Coda and my Moana is in Ul!arca and affect. <br /> Lioensa t `7(909 AI Expiration t»: 43U/ <br /> 0 -Vi lli 2 enr-466.A,Z) c <br /> Too: A/ <br /> PrtrMaa nanla- <br /> I hereby affirm under penalty of perlwy+one of tlfre fogowlnp dedsrstions: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a r N O to W Consent to 116144 aure for warhers' oompansatioM as provided for by <br /> Section 3790 of t4 Labor Code,for the Wkmmnee of the worts for whch this gimmit is issuad <br /> I nava Arad w W nViintairr woriosra'oornpena4bW brsurance,as requwad 6y Secftn 3700 of"Labor Cotte, <br /> for the pedomuanEa of the work for which flee perm*is Wmarrd. My workers'comprarteartion kwunutce <br /> carrier and policy numbers ars: t <br /> Cartier:&Ben <br /> fes,k, Poday f6wober: <br /> I cerft OW in the perlornwtze of to work for which suis permit is issued, t shall not employ any parson%n <br /> any manrarr so as to boom*subpd to the wodaers'cons naembw Iowa of Cas koma,Bad agrpe#ud g 1 <br /> should become subpd to Mho wW§usfs'oomperwation Provisions of Sonfina 3700 of the Labor Code, t shall <br /> fh o ply wRh those provisions. <br /> Data: >6iSnsRun: <br /> Z,;, <br /> PNntad I"-- <br /> UUMNOW:FAVAME TO SWURE V10MURMCOM pM4lT)QN COVINAE K UM-AWFUL,AND WALL SUBJECT <br /> AN 11110"ATt M TO MINIMAL PEMAL7M AND CIVIL FV"UP TO ONE MP DRED THOUSAND DOLLARD <br /> RD i <br /> C9114kO1U1. SM A00"1016 To ME OW OF WMAMU,lNTONW,ATTOR11MV S FEJM AND DAMAGES AS <br /> PRCVWM FOR Mr SNCTWN VM OF Tt%LADM CODE. 1 <br /> I <br /> L4 ------------------ <br /> ft- l -KIck4clanz, <br /> ,s7lfoa,s.a�,fhotts.d w�trersby <br /> .ulhor#se <br /> Is s*r alis sen.toagtaki Courft w.0 Pee"Apptbostion an err b~. I undaratand Il is m*hori:aRlan is vsud foR <br /> afN M and r tiAM"b to we*Pbe dated M the ft=st M of Mls <br /> £ 'd V*I*i-1 i h+T7S:0 1 SM t-VO-CSI 1 <br />