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I .fir <br /> z:5 Pi RMIT <br /> �� ADDRESS <br /> , : :: <br /> '� y .:.:�". ..-.. ,'' ' ' rti�'^,;r ;A'•.r:`..i �h,o.. �""" ?�.'if'_' �°tL~.'.it-'.a.' _ _.-.� .. <br /> �:��'"� :ahs'J' -:rx'.k�'�TiJ4� S '�:—74I• � ..:�'*'�^�"t'•7.d'2.�'".....t.r�. ..i�_.++";' <br /> LICENSED'CONTRACTORS DECLARATION ( .} <br /> I that l am licensed under the provisn e <br /> ions of Chapter 9 (tornoinp with Section 7000 ot Division <br /> herobY III <br /> 3 of the Business and Professions Code)and my license is in ittll force and eiier rl ' <br /> Expiration Date: <br /> pate: Can <br /> _ia <br /> Title• 1 <br /> g)lanature: III <br /> Printed name: <br /> WORKFERS' COMPENSATION DECLARATION <br /> r u one of tris tollowing declarations: (CHECK ALL TIJA'T APPLY) <br />€ I hereby'atflrftt <br /> under penalty of pe,� ry <br /> and will maintain a tel"0010 of Coll ssnt to self til the work fnrure for kwhich this permits iusnsIti On- as uedVldsd for by <br /> have performance a <br /> $action 3700 of the Labor Coda,for the pe section 3700 of the Lobar Cede, <br /> ` a work' c which atl permit lg issued. My workers'compensation insuI <br /> 1 have and will�'r�8�of t�rkera' campensatlor inauran�h as requkred by ' <br /> r"n <br /> carder and policy numbers are: <br /> Polity Number. U <br /> ZL <br /> Carrier: person In <br /> perm <br /> i3 iSauBt3, I shall not err►Pfoy 8r5y P 1 <br /> 1 ceM4 that In the performance of tht work for worwhIkers <br /> this P nsatlon laws of California, and agree that if 1 <br /> en manner so as to become subject to the workers'compo <br /> Yt to Com ensetion provlsiaras of Section 9700 of the Labor Code, ! shall <br /> should become <br /> swbthe thtrsel provl!on. p <br /> forthwith comply <br /> 0/1 <br /> Date: !f 7� zvoc Signatvro: _ I <br /> Printed Name: '4`�" <br /> IFUL.AND SHALL SUI <br /> WARNING- FA <br /> ILURF TO SJI WaRKSRS' CC CIVIL <br /> FINES UQ TOON YONEHUNDReTHOUSAND D MAGES AS <br /> AN EMPLOYER To CRIM1NAt-p£NAt.7l1= RS <br /> $AND pEN F <br /> ($100;000-11, tN ADp1 ftQN TO THE C fSTii OR CODiON' lN7ERE5T,A7Tt1RNEY S FEES, <br /> pppVld£D FOft Ito SECTION 3706 <br /> (C-87 license haldor),fttineby <br /> 1 nrzh7� <br /> !� gy.oonsuttinW sign tripe son <br /> ►TT4c� of �✓• �G� f <br /> euthorizc �'� <br /> yV+61I permit Application on my behalf. I understshd this authorf7ation re Valid,for one{1)Pear <br /> Josquin County llcstlon. <br /> ' <br /> and is Ilmitod to the work pian dated on the front page of thin:app 3 <br /> . i <br />