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• X1009 <br /> Sen J"gdln County Envlrohntsntal Health �fe <br /> Rartment Unit 11f W'"PEr'mit ApRllakflort Supplement <br /> J08 AQC'RIESS: <br /> PERMIT SR* <br /> LIM"E,D C0IUTRAC,TGRs DECL,RATIC)N CLM <br /> I hereby affirrn that 1 am Ileerlaad under the provlafona of Ch <br /> 3 of the Business and professions Cone and my I ions O is in full force(commencing wfdl Section 7000) of DiVigion <br /> License#: 4 <br /> Expiration Date: , <br /> Date: D' <br /> Contractor; q' <br /> $ignatune; I <br /> Title- <br /> Printed nerne: Title- <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of penury one of the fajN:?Ming daclaratfona; <br /> _I have and wilt meintain a c�srNflcate of consent m ( "PECK Oros) <br /> by 8action 8700 of the Labor Code, fpr the parformOnesrton D for work keml c <br /> orrtpis Pq on as provided for <br /> i have and will maintain worl�rs'coon which this permit le Issued. <br /> for the pensaison lnsun�ae, as required by 5eetion 3700 Of thlo Labor Code, <br /> Peri°coley n of the work fqr Which this lSerrnft!s issued. My workers'coat <br /> carrier an�palicy numbers are. <br /> Pernsation insurance <br /> Carrier: 1 <br /> Polley Ivurnber. <br /> i certify that in the performance of the work for wh1oh this e <br /> any manner so e9 to becom®sub)ect to the worker:'comps meIs lon�40d,Chale n la, <br /> should batvme subject to the workers' +rrtplvy any flan fi <br /> forthwith comp with those cOmpansaVon provisions of Section 3700 of the labond gr Coded shall <br /> proviafons, <br /> it I <br /> Date;.X II lA <br /> Printed Name: • <br /> ►N 1!NpLQ F�kILl�I;26 I iECW.isi, WORKERS'OO111PENS�,TION COl/klgAOi <br /> 4itl L�iPl.OYEA Td�RIMtMa�P lAET1�5 <br /> AND O�c Mlfri�9 LI:tCri oaE41 <br /> (5709;1 y�r IwDfillTIO111 TO THE t;6tgr OF CdMPEN A14LISATX)kp fp ro 0 qr lqW p YH���4hlfg SMALL$4/B.If:C'i <br /> PROtr"D FOR IhI SOCTICW 37%OF THE Ug6t]R CODE, 9 FRfa Bp�pLAMA tlES AS <br /> AUTHORIZATION FOR Pj2ff—RTHAN (x•5751r;NI-NES PEFt NT i4,P <br /> ►, PLICATIiSN <br /> herby authorize(print �( 9n■tures a+c-s7 Rcer,�a authorfftd rmprat■efative), <br /> (P rn nan�I � <br /> I*$lpr this Bah JOapwin faun --" , <br /> �Y�ltl Parr1TR APpflo■tton an my hrah■tt. i <br /> 0 (1}year and t® undbratene thin autharlraiipn Is va�Nd fer <br /> 21rlmtt*d to the work plan Med on the front page of this appwl"Vort. <br /> 8.29.02!MI <br />