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01/03/2008 15:18 <br />t <br />art JOa trill C <br />209835 X75 <br />ZOIJOSon <br />IP <br />2098350675 <br />1t77GJ�nO / II <br />Department uhUit, IV Well <br />TWWAk-91M a 5 ' ,- - <br />PAGE 04 <br />rte nc <br />I hereby offirm fiat I am scmed under the provisions of Choptw 9 `commencing with SeCW 7000) of Division <br />3 of the Mnlness and professions Code and my licame is in full tree and effect. <br />License #. i'n � � � t F*ration fie: <br />IOiata: G - (j� _ Contractor.�- <br />S;�rleture _ TRIG; <br />Primed name` <br />I hereby affirm under penalty of perjury one of the f®Ikuntg declaraffians: (CHECK ONE) <br />_ t have am will maintain a ourtificaw of ransardi to *Off4rmur® frit ' cmVe'rfsMon, on prc%ided for <br />by Secticri 3700 of the Labor Code, for the peftemance of the work for which this pem* is issued. <br />om and Will m worikers' compensation klsursntce, as regtAred by Suction 3700 of the Labor Code, <br />for <br />r the poftriytaneg. of the work For which this permit is issued. My workers' compensaCtkm insurance <br />Carrier and policy riumbers are: <br />carder: t -A - Policy Number <br />I certffy Shat in the pearfarmaanam of the work for which this permit Is Issued, I shati not arnpldy any person in <br />arty manner so as to become subject to the worXers'co"nsation taws of Calliornia, and agree that if f <br />should become subject to thou workers' comperougan pmVisions of Section 37010 of the Labs' Code. 1 shall <br />Foran O comply with those provisions. <br />Expilradon nate: 9/0 ? Signature; c _ <br />Pri e•7 =SC.•fi <br />[r-.CMj)RD FOR IN WCTI ON 37% OF THE LABOR CODE. <br />AuTHORIZATIONFOR 0 THAN C-67 SIGNING PERMIT APPLICATION <br />1, �:�' d &:�e -caignawre amJ7 Iftenzed . represenolvell, <br />hereby authorize (paint <br />to sign utile Sari Joaquin r-MMTy <br />one (1) year and Is fhnited W the <br />EM 2942 -Mi <br />4~ftaa <br />L <br />Fermit APpUcation On aq behuU: f understand this mtherIzat6an is avUd few <br />pian dated an the front tie of this applicwrbrbrs. <br />