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WELL & 60RMG �EMT APPLtCATION bUPPLEWIENTAL <br /> JOB ADVIRESS Li PERW"Vvp <br /> LICENSED CONTRfir"TORc nEQLkFRfi7'nN <br /> 1 haretry affirm that i wn*,armad under the-mrVm-brts of f-tmpinr'9 Icammenrftnq with Satton 700)of <br /> division 3 of the Caidomia Business and Pmtessiorts Code aria my;cense is m lull force aria effect. <br /> Z",oiiluacwr <br /> ' iron-r <br /> S7 rNnA Opt,,,. 4 ?,,"l <br /> Print Noma-,. -Km4N R SRS "eiterg,V-17 <br /> WORKERS' COMPENSATION DECLARATION <br /> re b F ind e-pe r,a Y <br /> hm—e and .%All CZ;!tTr-:Ar- 1-6 rr-,r.cr-r.: <br /> !:%ermit k- issued. <br /> L <br /> compensation, insi,rcink-.& and nd'cy P-jmb-er3 <br /> warriey-. Staiieiurtd Folk-,y Ak Exp. DOW $wii2ipia <br /> q I I <br /> lvr P-- <br /> 116" <br /> h <br /> VL <br /> L <br /> WARNING: FAILURE TO SECURE WORKERYS� PEN'S'ATION COVERAGE IS UNLAWFUL. ANN SHALL <br /> SUBJECT A" fV.PLOYIER TO CIRMNAL PENALTIES A"D '-Mt FNIES UP TO SIM'YD13 iN <br /> Ht_avViLfi Ali -it 0-F GGM�ILISSAT(0-'%, i�,*YLI kES-k, Ail bAMAGE,� <br /> Ai O�li�►7ii jaTiaitf POP 0-RFP THAN r,-57 GK-,koNt-, P;=RM;T APP; UATi(lN <br /> oyauthorizationis vaild for 00e v ,#" <br /> authorization fl * to,herethe work n da on front cooe of this aoolicatioo. <br /> EHD 29-0I 8-1-2017 Ste mtomabm We4eBomm,Pe-mi Arvrito- <br />