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1/1(1141-1.5"76 /1v adfro? <br />g52, <br />San Joaqinn DouelY Unit IV We Murk SjipØeriwi <br />JOB ADDRESS: 4g4Eara1 saft.S.ftvatt_p2,_ <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />1 hereby aftlmi that I am licensed underlie proons of Chapter (airnmencing wilt, Section 7000) of Division <br />3 of re Business and Profeserens Code and my lieense is in full force and effect <br />License # 41- CY 5 I is 5' Exprrabon Dole - <br />r-011 Litri <br />- Tide: C V:171 -1-1,6"AS aroz <br />(Actri f) <br />WORKERS' COMPENSATION DECLARATION <br />I leeby affirm under penalty of perjury one of the 10110Ning dedaratioreK (CHECK ONE) <br />i hire aria Bin mairrtain a certificate et cement to sed-restens tor wcsicers; coreipeesaiion, as provided (or <br />by Sect= 3700 of fhe Labe( Cone. tor No performance of the MCA for vittch this permit Is Issued: <br />_I have and will inatnbain workers' tempertsabon Insurance, as required by Sorban •3700 of the Labor Code, <br />for the performance of the waft for Venal INS permit is issued My renews' emnPeovatisn insurance <br />carrier and pokey numbers are: <br />--r <br />Carder --„Y. rj, v .) loamy Number: fjJ <br />I certify that in the performance of the 'ask far which this permit is issued, I shall not employ any person in <br />any manner so as to become subiect to the workers' compensation laws °Maoris* and agree ihat if <br />I shared become: subied to tie workers' oompensaban provisions d) Section 3700 of Me Labor Code, I shirt <br />kirthenth comply noel those proesons. <br />Eitpliation Signaiamt rl <br /> <br />Printed Name: `-.1 k k. <br />WARN(NO: FAURE TO SECURE Won:cots, cemPoisknots covERMX5 umAlenn_. AND SHALL SUBJECT <br />AN ETIPLOTER TO CRNMINAL PelefiLliES MID CM IFINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />tsiocao..). <br /> <br />is AMMON TO THE con or comPrmsAmoki/ITEREBT„ ATTORNEY'S FEES. AND flikailikeES AS <br />PROVIDED FOR al SECTION MN OF T1* LABOR CODE_ <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1ft-O (slinnaliate. airdiorizad wiessernalive), <br />her. K Cro- it tLi Cr/ eke s tizv't/ <br />lorroby authorize (print nowarj <br />to strer me San Joaquin Comet,/ Bei Pima Apprwlifion as ony behatE I understand this andiericaSesi is valid for <br />1 one (1) year and In lienned ta Use work Omnibus's on Ise front paw or this itipplirneon. <br />1 Las-az i <br />Pao: <br />kjrciturra: <br />Printed name: