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' OCT-02-2007 16:52 CAMBRIA 1707 935 6649 P.03/03 <br /> ..., ...• �rarl lon�rl �/� YAT( '145 6649 P.03/63 <br /> San JotlgYtn County Emrironment d NOW*tbparonant Unit 141 W611 P6rwtApPllm90n SwPplarrrent <br /> JOB,ADDRESSU'�! &TO,C4. PEWIT <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby aftft that 1 am demnsod under'the provisiCM of ChaPW9(rommencirrp with Sedim 7t] O of DivlSbn <br /> 3 of the OWrnsss and Proft%Nons crone and my kem is in full form and elfert. <br /> u M Fxp,nsdbn Date: 04-3/-07 <br /> Dam: /d- D /^d7 Co &Pfd <br /> ImW: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penaity of pojury one of the folktvft dad; m fir,na: (CHECK UNE) <br /> ✓ 1 have and w04 meinbain a aeNfcale of carm►t to aWnsum lbr woo twW comp w mtkn,as pM iOM i'or <br /> by Sermon 3700 of the Labor Code.for the podarmence of the vowk for whish this pmrwt is immd, <br /> 1 have and will nail* in warkers`compersotion insurance,24 mquimd t&Section 3M of tho LaMar Code, <br /> For bia pra*rtrrsr W Of he workliV whkh this permit ie iusued. Mywo*md=wrqwmWdmwdwrm <br /> carrier and POW mmbem are: <br /> Conttlr: ,2urslcoa 62trcAj f� Nurnimr. OJS 22-CSt N-12a <br /> I car*that In the pettforrnance Or the wrek fOr which INS pKWL its is3urad, 1311211 fat ernplay gny person in <br /> any mwmr so as b Ire=mw subject to ftw waftW cpmpensadon 1a*!of Ca fonft strict agm hat It 1 <br /> 'st'Io M become sutge d tra V e vYetilere mnpon mom P vislons,41 SeMan13-101)d the Labra Cade, 1 stwil <br /> forthwith comply volh d umn pt, &ionm <br /> ExpiratlonOet GY�a9 Mgnatmei r`" <br /> Prinw pis <br /> IMI mMNGF:FAILURE TO SWORE WORKEFW COMPE?MA=H COVERAGE N UNLAAMIFLIL.ANO SKALL GULIECT <br /> AN EMPLOYER TO ANAL PENAI.TES AM13 CrAL FrNES UP TO ONE HUNDFJM T)IOUSAPM OOLLAlks <br /> Ih%VW IN ADOMOW TO THS CCV OF CCMP W$PiTICK 1ttTF.REST�Arr'ORNEVM FE'E'S ANA DAMAGES AS <br /> PROVR i FM 1M=CTICN 37M OF THE LHON CODE <br /> AuTHORIZATIoN FOR OTHER THAN C-97 SMNING PiE lil rr APPLIC,ATFON <br /> t c.,f/ryr� /� • a 7�lfCreA7+r r allinaar►r 9IC-47 Ilt atimW aWhodand ro <br /> Pn�UOra). <br /> horny ntmmw a(p ftt rwww a r`i+' C krw�s d C.R.A . <br /> to aiplf thV9 Sur J024ulh Cc MAY VMI Petrgtt ApP11=90n on ary , I under b d thls aiunratr"Un is wwAd ftr <br /> arta(1)Ymr and In OMfbd iso um work pian Octad on the front paps rn this wppitc91bn, <br /> e• r <br /> TOTAL P.03 <br /> TOTAL P.03 <br />