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2?d/ <br /> rraurmnixt Keay r ut tMi t fV Won Penult Appkc/at�r,a,.�n 5 Picnw"t <br /> i`San foaqubn Cuueiy .y <br /> j JOB ADDRESS. .. !t' RERhVT <br /> i <br /> LICENSED CONTRACTORS DECLARATION k.Co <br /> 1 tw3feby afUrm?ha<1 ewa liderwaed hider the pravisarfs d Chapter'9(rnrJrzwndrt9 wi6t S�CtiWt 7t#fO)of Division j <br /> 3 of the tat and Profe$WWK Code and my bee nse a in hof:acs and rJpert it <br /> Ucanse <br /> Contactor ? <br /> !J7A <br /> Printed name: —.___-.— <br /> wGRKERS'COMPENSATION DECLARATION <br /> N one of the idfowing dedaratjarm (CHECK ONE) <br /> I twTcby ern under penalty p�Y l <br /> _I have and w W1 mabdain a died rmsent m sewiwrte t+Y wal�rs'PFA <br /> ion.as provided for <br /> uy Setbat 3700 of 1hee Lde <br /> Labor Co .for The Pwkxuwnce of iire Work for V* VMS P iS Is .0. <br /> I have and wM m8cntam workers r nngen,.�on hwarance.a rt�rPnrea q Ste`�7if0 d Lite Labor CoOe, <br /> fo the per{orroartoe d ttfo r atk fa;w#w;h thm p is mwjed. NT worker6' irtsul nos <br /> comer mvi PokcY rxs'x"m are' _ <br /> i (,Tiler. i <br /> I curtty ilial at the pariot"nce of the work fa wlvch thm pe++w a sued,;shall not ernpkOy anY Persat,'n I <br /> airy manner so as 6a became f�bteel to Mie maximrs'c�erwatim kw=of Cawwrae,W4 agree that d I <br /> shmW become m*Wd b Ore water:aom afinn Wam om(4 Seetlon 3700 of ttq!Laoor CoOe,1st all <br /> fmrwAlh cornply watt twee waveons. <br /> Eim-watlon Date: --- <br /> c'nnted --- <br /> I <br /> WAfuxWC;:FAILURE 70SFCURE WWOR KERS'COMFENSATKSNC01161iAGE IS Utt+tYYFlst Alli)SHALL 5UB ECT <br /> + ER 70 " 1001d"PETAARTWS AM Chid Pilaf Up To ONE"WRED TW&4SAWP DOLL <br /> AN E&WWYARS <br /> (iioo,00�.LR6ACDITk3MTO7T1i GUCiTOFGOMPEWt41iT%all.t/3tiEST.ATTORtir'+iIFES.lPiCYDAMAC9F_SAS #{ <br /> j i'ROVWW FOR N1 SECTK l 37"OF THE tABM C00C: <br /> AUTHORIZATION FOR OTHAN C-ST SIGNING PERMT APPLICATION <br /> i ) � <br /> I�,_.._ ?-�-- —�.-� t_—�-.is�^'�"•c erC�7 Gce,nee ara+oNz.e represa+A.t4ve►, <br /> agrael <br /> a.arebyasaaiiralwiA - � �=��_�— •wtidfo[ <br /> ,sign Wo Sao joagWA Comity 91hd1 PM1wd Appiieation oe alt behatf- 1 um1ws�tkba�YroorvalYsw <br /> i,,awe(i)year aw ki limited%o the work pian dried on the troll par of this Wheabon. <br /> wva <br />