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FM 2"1 670M WELL /SPP <br /> ow &W I <br /> &Somme Pwwrr A -nom SuppumeNTAL <br /> JOB AP z PERMIT Ste# <br /> LICENSED CONTRACTORS DECLARATION L } <br /> I herehy affirm that i am Acensed under#te prov' of.Ch 9(commencing with Section 7(00}of <br /> DW Ion 3 of the Susfnmand Professions t my license is In fug low and affea <br /> Lioense#: . EXp Daft: <br /> Date: ,1�1., a1 aa�,r� . UcC CD. <br /> s Wires c 4e!v� <br /> Prat ice: �_o Q C-101 c- bkkted <br /> WORKIM'COMPENSATION DECLARATION <br /> I hefty aftm under penalty of ty one of the following dectw4lons,(check arm) <br /> I hove wW will maintekin,a cadfloete ofoormed to tf-Insure for as <br /> pmvklad,fm by Section 3700 of the Labor Cods,for the perfwwfm of the work for wha,this <br /> Is <br /> i have and wffl rnsintain rkors'compensafton durance,0 mqulmd by 37(*of the <br /> ,for ftperfomwaos,of the work for which ft pmmft Is lesued. My woftW <br /> compenudon i! nce r and n ars: <br /> Cartier. 5 P a, r ��. Policy NuMbW. , (1 l J$ 4p <br /> y that M the perfommaoe of the work for which this permit is ismod,,1 shall riot wgfty any <br /> pown In any manner so as to become subject to fire workers'compensa, don taw of Caifarnla,and <br /> + agme that tf 1 should become subjed to workers'coffVeneallon provisione of Section 3700 of Me <br /> Labor Code,i shell ftftft,cm*WO thoeb <br /> i <br /> Exp. : SIPRWM: An�� <br /> Print Plante: <br /> VWUUWWi FALUPA TOSWMI IS ANIS AN OM To <br /> 1'NIIAt nu Allo tam CIlM =*`IQQ,gA INAWrION To YM COOT of MON,WTERMT. <br /> A S1"PUS,AND A8 PROVWW FOR In MWM 3M OF THE LABOR 00M, <br /> AUTHORIZATION POR OTHER THAN iC-57 SIT . ATIGN <br /> I. <br /> toWnsture of C-67 ), <br /> to <br /> sign this San Joewan County sodnp Permit AMOodion an my . I undwaland We <br /> is vdm for am yor is NoWed to Itw work plan doftd on the NO pop of MU sppkWon. <br />