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rKUrrt�HECISfON SAMPLING �k <br /> 191510430 P <br /> TO 68 .01 <br /> Start Joaquin C0110W Ensrironfnentel> Se Amt,UnllttYwell PemvFt Annil <br /> 13 ADMESS:161 PF-Ruff Sit <br /> "M uttCi4 IL <br /> �ALYH <br /> NVll,,;itiiVl, <br /> UCENSED CONTRACTORS DECLARA71ON LQ �ERWT/SER ICES <br /> �i <br /> I tweby alf'irm goat I am ticeMed under to provis6ans at Cttapw 9 foommanc►ng with Section 7040)OF D"iv� <br /> 3 of the Business and PrdOsskms Cade and my l Anne";is in full fora®acid effect. � <br /> Lkense* -3'8'Z� _ .. F=iravanDaze: 3 t o q <br /> Dale: Z 0/ Contraaror: l e •;' sa^ I Q I�� <br /> signature: ._ <br /> f <br /> Prinwd name: <br /> WORKERS' C0MpF_uSp,TM DFCLARAMON <br /> I hereby affirm under penally of>W}ury 0M Of the zgla g mss: (C#iEf:1C ALL THAT APPLY) <br /> I Marne and rMlll rnainlain a certlticste of OMsent tiorktSur'e to r vrol'kers'COn7per+satict,as prositded for by <br /> SWAM 37Do of Ow labor Code.forft Hermance of itre work zor which tlna Pe'"'t is Issues']. <br /> I <br /> l brava and ricin main#ain woken'CcMp63s00n i�s�r���read �re �a� �Cods. <br /> fps the p0dj0 mance of tfie v cork tar which this pe MY <br /> insTsmoe <br /> ZA,J `� e I tls�mber:GJG i 67 A 07 L334 _ 010 t <br /> cao' er. pd"`ry <br /> I seaity that in the pedmnce aat the work for Wtilch this PWWA is issued.f shag not employ amperson in <br /> any ffk-www so as to became GuWvek W lbe wa&ff, 'cWnpWw on bm of CalforrAL WO 69M that If I <br /> Slto�il<I Mme WOW is tlye v+orlpsrs's Ixcaiorts of Sedior�3MaF to Labor Code,f shall <br /> trtl"M comm veth V*W proal ms- f <br /> Dom <br /> 5lgrr>rtorer <br /> Printed F(WM: <br /> WARMG;FAILURE TO SEMME MiriilRKMW CODPENSATIMI CQVE bE 16 UNUWFV IWf?-$iiAL SUB;�T= <br /> AN EMPLOYMM GRIMMAL 90jAL"t5E6 Aim QVIL FINES UP TO OW HUNDREDTMON6 OOLLAI <br /> jS110a.caa).rH ApXWM TO THE COST OF COMPENSATION.CREST.ATTORNEY'S f`V.AMD DAMAOIR AS <br /> PF CHOW FOR qct w fIOW 3M OF THE LMOR WDF- <br /> rwm <br /> afO47 ik eooed gnaw ted apmer <br /> Herne ��,Zg Q. �rpT� r S <br /> m sign g"S=j0a"In Coant Well Permit Aogwgo t oo my tea I�d thus�a Ls vaid fafi <br /> one(ij 1w and ft&MMW40 the+trod[pian dated cm It i 1104 Pa"as nils a fflftatloa i <br /> $117-ZM I JIII1 E <br />