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Jul 530-88r�rr;Joe p.2 <br /> ! F <br /> ^aan.laaquirl County BrKirArs�ental}scalls~Serrricen,unit N W-U PermitAppiieadch Suppterne <br /> JOB ADDRESS: <br /> J1 <br /> PERMIT $R#: <br /> LICENSED CONTRACTORS DECLARATION LCA ' <br /> I hereby DMM OW 1 otn liaexssed under the 13MASIMS of Cttepter 13(convner+cin9+Kilts SeoUon 7000)at Division <br /> 3 d the ellsfness and'profusions Cod&and my licanse%in full(arca ai Adoff$cOt f <br /> License#: • �ira4orl Dat,E: J` J <br /> Date: <br /> -� Gontractar: ' <br /> Title: <br /> Signafure: <br /> printed accrue• f <br /> WORKpRS,cvlu�ENsanaN nECLARATION <br /> arts of life fallowing declarations; {CNECK ALL THAT APPLY) <br /> I hereby affirm under penalty of p�lY <br /> I hs<ire anr3 wig rRaerftain a txsliflt:ate ormraent to self-lnsure for workers'compensation,83 Provided far tsy <br /> Section 3700 of the Lab or Code,for the performance of the vrexk for+which this permit is.issued. <br /> I have and wfli maintain workers'zcMense n Insurance,as required <br /> b S.ctio ensa on Irthe <br /> L2bor code, <br /> For the performancc of the work for which this unit is issued. My P <br /> carder and policy numbars are S f <br /> Passey Number• o <br /> Carrier: <br /> 1 celtifyttlat in the pedormanec of the wofk for whIch this perrrtlt is tssued,I shall not esmploy any person to <br /> —any manner so as to eecorrie subject to the worRafs'cortipansation IOWS Of California,and agree that it i <br /> should nner o s 10 b ro ne'rNorkars'eompenatilien provlslons of Section 37ao of they Labor Code,i shall <br /> forthwith CornW with fhcsQ Proud - <br /> Dater: <`d Signature: <br /> IIII Printed Name- � <br /> WARMNG:FAIL GTO SEC P1`NALTIESAAti IVL F��S t1P TG 0 NU"Up=IM SAND 1OLLARS �EC7 <br /> AN D,WQ.Nff ft _COSTC)f <br /> PRt7VfDl:P Ft�R t[d1[d S��CTIC�I'!3709 Q THE LABOR(MAE.�����ATYGRTtE'4"6 Z�E8.AND flAMAQ>;8 A <br /> I, � � _ �� �_,. � �.� �IC.sT Ilcematod atalhotixadrePrese!rlta�ttve),�bY <br /> authorize <br /> to sign Mb San dea4uin Geeuntt►WaF1 laeres►itapP <br /> tlgf Q1V a MY behalf. t undafstand tuts authorizaUort valid fol <br /> one M yrrerrari Is Treed to aha work Plan detail an the front pr+ga of this NPPU111 oil• <br /> 31T-isQ01 Ni <br />