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IICENSE�� SS � LIG.NO.-��'�F'r-' i V _ � .~"� 'DATE �.. � �... �^" CONTRACTO J W: ���� 9RK RS'COMPENSATIONDECLAfiATiON —� ¢ '�.�'; ''�,,;IHEREBYAFFIRMUNDERPENAIT OFPERJURYONEOFTHEFOLLOWING�ECLARATIONS: Z ���,Z, '�.,_INA�EANDWILL,MAINTAI ACk�RTIFICATEOFCONSENTiOSELF-INSUFEFORWOFKERS' $ CDIApENSATION,AS.PRO IpED;BYSECTION3]otlOFTHELABORCO�E.FORTHEPEfiFORMANCE U �¢� OFTHEWORKFOR'WHIC THI9PERMITISISSUE�. � � ,�„ "_I.HAVEANDWILLMAIN7AI WORKEflS'COMPENSATIONINSURANCE,ASRE�UIREDBYSECTION ,/� �, '�Q�,�.'' 37000FTNELABOR.COD.FOF{THEPERFORMANCEOFTHEN/ORKFORWHICHTHISPERMITIS � /����p ISSIJE�.MY WOFKERS' MPEN TION MSUftANCE CAFftIERAND POLICV NUMBERARE: CONSTRUCTION � Id��/ ° � �, . �, , cqRRieA PLAN REVIEW Z PoucvNUMeea ELECTRIC Q , �, (iHl55ECT10NNE�NOTB�07MPLEiEDOFTHEPERMITISFORONEHl1NDRED00LLARS($1m)ORLES^a). PWMBING �W � ICERTIFYTHATINTF7EP9RFOFYMANCcOFTHEWORKFORWHICHTHiSPEFiMITI5155UE0,1 MECHANICAL ��, ' SHALL NOT'EMPLOY ANY ERSON IN ANY MANNER SOAS TO BEGOME SU&IECT TO THE '(/j. 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