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3u 1• 24 03 It-013a GH14 EHGIMEER 11 ��'�, � S3t7 886=31Q13 -2 <br /> s � <br /> ? r k <br /> �, � 4 rt�tlon'SrrtPPiement��° ` ��^ <br /> San Joag�n County Eryvirantaenkai 1{ea1Rfi SCfYiC�Sr - � ► <br /> JOB ADOMS. <br /> S-aC� � k`PER�{IT SFt <br /> ` �I� iC13 <br /> LtCEA1r.S CbNTRAGTORS�ECLAFtACn -----� <br /> @f 9(comrnettcin6.xith Seatian 7000)Ct61.1wD1ws <br /> I hereby w.M thai 1 am Gcerised bitter the pro, lic n e ronfu <br /> 3 of the susiness and Pmfessiores Code ertd My IicAnsa iron full Force and etFeei. <br /> 00ration Date. 7" <br /> uceme#: 710.0,7 (,,30b�w A►� fti�.t_ir3 Ca <br /> Oste: 7 Zy-03 <br /> A6eQ. <br /> Co Tfa.jS PsiAa1 <br /> Tale: <br /> glynAturt: <br /> Frlizted name: + . FIJI SST1w"'-•--� . <br /> WORKER'cowIPENSATION DECLARATION <br /> orism of e4ury one of UM falitis�icrg de latahons (CHECK A"THAT APP�ti!) <br /> I heretly affirm taster P 4 _ enwillm.es provided for by <br /> _ R♦�ts perrrn�is issues <br /> Seollonand WiTl 37On of the Labor Code, RtsQ p�arnsan 4f the vrorlc fiat r ioi+ <br /> cts <br /> ,his permit is issued. My r�rartcers'�arrapeiis8titl:t Utsurance <br /> tbave and will rrraaslsln•w wkor�k fo�pertsalioa Insurance.as'equired by Section 3700 of the 9,8bdt Code, <br /> I <br /> for the performance of the <br /> carries and v llaY numbem are: <br /> !►? TEE PalicyNumber <br /> asrter: I Mn ersan in <br /> ` rript:i75aliart kituvs of Cajftrnta.Bad a9me Itrat ii I <br /> I pettttylfiat to the Ppforrnanix oFthe+�ds lar which this permit is issaed�l shah not emp ay Y <br /> any rrranner so as to become s6tjar t to the woAters tons of Secimn 3701)of the Labor Cade.!strait <br /> should betoma wAect to the workars e6niP6ns2ti4R <br /> fortkwrith aamplY vAlh JAQM provisiot+s. <br /> Signature: <br /> . <br /> printed memo:.. <br /> MATlCll�t CavEptA W 4 UNLAWFUL.AM SHALL SUBJECT <br /> r <br /> YIARMING:FAtl.RlleE TO SECURE WORKERS'C t�_Y'S fr'lGES.Al(ll pAIIAGES AS <br /> AN EMpLOYERT�4�N�O 1 RtE COSTO COMPE�01`4010"Hij IN R>"ltE,5'Y, 'I tkDt351WD DOLLARS <br /> P FOR Int SECTION=4 OF THF.I.ABQR Gd <br /> F� 55TGa'''; . ( sedas+thostzsd nepreme <br /> ntartve),Acre�y . <br /> aa�efsgatrs =� 6 � <br /> tosign tlris San dea4ui>.CasuNp welt Perm:APPkieation on mybehaif. t UnCIaT Und ttais auar9tisaltart yaiid for <br /> 0M(4)year and 3s lTmftd to the wo*plan dated an tha ftMt P3910 of tits%Mocailon' <br /> &1T.�004 f itl - <br />