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12/0512000 10 29 7073745677 WOODW49D LRILLIW3 CC F4GE 03 <br /> LSC-S-dwg 1P•gaQ Fp(SM: <br /> TD' '-e7374.%77 <br /> .ad <br /> ' Son joagWm Couwty 1 nn— nmantel Health Servlcars,Unit tv Weil permit Applleaffen Supplement <br /> JOB AD0RESS: PERMIT SM6 C) Z��S <br /> 1 <br /> i. CENSER CONTRACTORS DECLARATION LC <br /> Z hereby afton that l am freed under the provasioru of Chep4er g(carnrnenwrg <br /> with SeMon 7000)Of Lwt&rOrn <br /> 3 of tho BU-5rnefs and proraa*)* s Code and my rcenag 16 in full fbrCa and affect <br /> Lk;eraae# <br /> ,f!:�'e—4" <br /> signature <br /> 'f'lttar: G0� r <br /> primed rkarad: <br /> ' WORKERS =MPENSAMON DECLARAMN <br /> i nay affirm w"Vr pelttltty Gf peryury one of"fal"Lng dmisrob" (CHECK ALL THAT APPLY) <br /> ' rhs we Wo WM M41nfA0 a QWtrf"tO of cansc+4t tC*Qtf-"W V far workers`oompensetuut es provided for by <br /> ......Seobw 3700 ot tfla f-.*W Gods, for!Ne DE'rfoemeeK4 of the wwk for whidt this permit a fsa>srd <br /> ' I ►have and w3# man'ain workefi6 at required by Sazfion 3700 of the Labor Code <br /> for the oar wrnance or the w9rk For whm;O this permrt w issued My wariter's'oprnoeirtssoort insurance <br /> carrier and poticy nvM1)er5 are <br /> Carrier. <br /> Policy l�ttrrtliY@f. <br /> I cWr y thV m the perWmance Of ow work for w6cxt na perrnrt 4 cssvea, I snail not emp"any pew rn <br /> any mina W ac as to bamne audl%g 10 V1e wo*em,cCvnpgr%xabor, laws df Callfom* and agree Oat tf i <br /> should become subject to t" worKWS`opmper%adlmn pro,6310ns of Seztxm 3700 of the Labor Code l argil <br /> 10MVA111 comply whir thole grovIswns <br /> Dale S'- Signature <br /> Printed(dame . . . <br /> ' WANG. FAJLURX TO 5 CURV WOPL"AS'C0AVltX&A*n0N VERAC"'tS UM-AWFUL AND SHALL SUaiFr..T <br /> AM I:MPLpYIER YC CMvI tiAL paxALTIMS AND CML RMS UP TO ONE HLIf+CR90 THOLM4MO DOLLA.R3 <br /> 01000(n).int ADDrrfo t TO THE COST op C1Olt MSSAT" WyMay,AT1teFtl EV S FEES.AND DAMAGES AS frr <br /> PRC'VtDM i=4 f&1 SECTM"3706 Ola 1`"E r, L"O"Coc*- 1 <br /> - i <br /> .ryc�.�r/� ��.�..� (C-57�oMbad authorlx�oo r�pritsent7rfhna}, Hereby <br /> ' ac+rhortlao��J � <br /> 40 sign psk Sart Joequorl GoWcy Well Pa(MA Appil adan on my behalf t uAdersia-rd thlra authQnZA OA is V%hd for <br /> ' <br /> one(1)year and is Imsted to 11te wart plan dared ort tho front pegs of this 100cabOft <br /> S-1 o r Flrl <br /> 1 <br /> i <br /> ' Ji r .3-z,6ew rpi is 59Am .Lor POGE 3 <br />