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LIC.NO._______�� f�T F �`,_..._.....__.___._._._-..._ � V DATE__�_Z�_�.. .._.�.__..... CONTRACTOH Is3�� d ' W �� WORKERS'COMPENSATION DECI.ARATION �� - � IHEflEBYAFFIRMUYDERPENALTYOFPI"Ii.IUHYONF()fTHFfOIIOWItiG�fCI.ARATIONS: � Z - Q - � IHAVEANDYlILLMMNTAINAGtRTIfICATEOFGONStNTTOSEIF�INSIJq[FORWOfIKGI1S' _ QCAMPENSATION,ASPROVIDEDBVSEC�ION3]f00fTHGlAAOiiCOf1L,�ORT4ICP[RFOfiIAANCE W OF THE WORK FOR WHICH THIS PEHMIT IS ISSUEU. � � w I HAVF:ANf)Wlll.MAIMAIY WOPKERS'COMVENSAfION INSUqM::C,AS!i[Q;Illlf:l)AY SFCTIOV ��J Q a�oo OG THF 1 Ar,p��(;ppE,FOfl THE PERFORMANCE OF THE WOHN FOH YlHICI�I THIS NERMIT IS � ,[ � aISSU[f).MYWOFIN[f7S'CqypEN�fNINSUR ECARR=RANDPOLICYNUMOERARE CONSTRUCTION __,.,,, _ _ ____ . � v f�. _ ��'A /�c __ > caHHiEa�[ J ...._. _ .____ _ . � PLAN REVIEW G -- �'J � .. ......... .....--- .... � YOI.ICY NUhIOER_ I �L-�L' J�(' "�`'� ELECTRIC � .._ _._.. .." (f � 1� r . ISSECi1QUNEEDIvOT6ECOh:F'LEfCUC1i�TIIL�� .."' 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