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11--� V <br /> jul• 24 03 11:088 GHH ENGINEERING <br /> 530-886--31138 <br /> San joatltrin Cdutdy <br /> Envirenraenlal Health 5crvicssUnit IV WoPermit A* <br /> ppgupplemertt <br /> IRR <br /> JOB ADDRESS• U�..._ <br /> S�ac� PERMIT s <br /> CA- <br /> LICENSED CONTpACTORS DECLARA'TIDN tt,_v_G[�] <br /> 1 hereby ars iron that 1 ern licensed uistler!h'8 visions of ChWer 9(commencing v.ith Section 7000)of Dlvisia+ <br /> 3 of the g, inns and PmfeWom Code and my ltcan Be is in tui!farce and effect <br /> O N: 7 I QQ7 9 <br /> EKpiraftn Date- <br /> . �,,SOp{�wAt?..� <br /> oste. 7-2q-03 O° -- - _ - - -- <br /> " — / 6� <br /> Title.•"6�2AT.+ 'S IriAn J <br /> gignatur�e: <br /> >orlrsted ttarr►e: �1..K �U�55TH"-`"�....._ . <br /> IIVORK.FtS'CoMpENSATION DECUBATION <br /> at ane df the f rats dam= (CHECIK ALL THAT AF'Pl-Y} <br /> I heretfy alFrnr trader penahY Pe�Y <br /> 1 nave and will rrsainisin a eertificale of consent to sell.Insute for wotloera'mmpen3alton,o&provided for by <br /> Segtion 3700 d the Labor Code,for th0 pakrmance Ot Ow work for Which this pet'rrat is issueet <br /> I hwitr and wig mainigm workers•cacnpen�tl�#nsUrance,Ssrequired by SeCtiart 3700 of the tstwr Cods, <br /> for the perfomrnl <br /> ce of the work for wNch this Permit is iswed. My workers'eonip"iaWn tnStErance <br /> carrior and paltry numbers are: <br /> carrier_ N FY't� Policy Number. <br /> -,�t Candy ihal in the pwforsnanoo of the wok for,Hhteh this permithissnllaws swe ,I C"�orMt y sny�Person in <br /> a"manner so as eo become tiubW to the workers comp <br /> should r ec�ama to the wakars dwoo+sawn lana of Section 3700 of the Labor Code.t Shall <br /> forUvith comply,vet thaw Provisions. <br /> Slgnaf+ e• <br /> th>te: <br /> Printed Name- <br /> WAWVtNG=iAtLtlftE TO ;W%;Iw WORltliltS' l0SATlO"COVERAGE IS UNLAWFUL.AMD 3"ALL St19J�1' <br /> AN i�)•LOYi RIC CRUk1NAi.pENA1711;g ANbG1VIL FtlleS ulF+TO ONE t� M9L AM AMAG S• AS <br /> Est 00.x.IN AoulTi�TO YIie=sT OF COMPEIeSATIOK tt�f TBR�`�"T, <br /> PROVtDtl)tM IN at:C17oN Was OF Im LAS=Cork'. <br /> 1, E <br /> 2,%� F0055?'Cc„'''�. . (tx-�t licensed aa,�ar�d r,epr�e�re),1+ere0y <br /> ante T� 6 � <br /> to sigthks San,iaer� w Cour"Well PermRARpilcm6m on mytxhalf. t dgrsland ttrar auR+ortctttort is <br /> s► valid!Cr <br /> ane{t]yW and is tiraltad to Lha wont Ply dated an the front page of this aWrmation. <br /> S-17-20001A11r <br /> i3-d LL9S-4L6-L0G-T pa8mpoom SUAR9 889=0T Co 02 ZnC <br />