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Jan 16 07 04: 16p G r r Dri 1 1 ing 56242' '329 P.2 <br />5E242423, Gregg Dr i 1 1 ing J a n 11 C7 02:34p <br />uiLfUf 13.41 <br />P 2 r14%.1L / <br />PERMIT SRI: <br />San Joaquin County Erwinarlinontal Health Department UMW Wed Penn% Application Supplement <br />JOB ADDRESS: T702 El tioigiseLL0 <br />LICENSED CONTRACTORS DECLARATION (L...C) <br />heroby teflon that I am licensed Lanier the prouisione of Chapter g (oonvnentino with Section 7000) of Division <br />3 of the gueinese end Professions Cade and my license is in full force and effect <br />license if LI- ('rS. I EXp onion Cote: <br />Oet UO lf Contractor- r,:.:-TC.1 ti ;?-1,,E) r <br />skin:mum .f•Jek d cfr.A1111A a /147A , <br />Hinted ems: 7-1-PCI, IN At. c <br />WORKERS COMPENSATION DECLARATION <br />I hereby affirm is penalty of perpiry one of tne raibuino dectanitionw (CHECK ONE) <br />I /wire and Als maintain a cercate of consent to self-Xisaire kremlin:us' compensation, as provided for <br />1:1y Section 37E0 of the Lotoor Code, for the perfonnanoe of the wee% for which this permit is iSsUeti <br />X I have and will maintain wortiere oompanuation insurance, se required by Section 3700 otthe tor Code, <br />tor the perforrnarioe of the work for Welch Otis perreit is issued. My WorKers' compensation insurance <br />carter and policy numbers are: <br />Carrier: CA to iick r•-.S C-6 Policy %anther: WL 10 io <br />certify that In Mc performance of the work for *lath this permit Is Iiicued, I %NM riot employ any person In <br />any mirror so osto baCOMe !Waled to the waxers' compensation laws of Catifornia. and an= that <br />snoold become sited to the *Wave' cormeneatiorl Previsions of Section 3100 of the Labor Code. I *hell <br />forlhwitti coniciy with those provisions. <br />/1 <br />Expiration Dew Signature: <br />Printed Norm: <br />ivotImit4M FAILURE TO sEctIRE WORKERS' COUPENSKnow COVERACEl USILAWFUL, AND SHALL subJEcT <br />A% ENIPLOVErt TO CRISIWAL pENALT1ES AND Chill FINES LIP TO EWE HUNDRED THOOsAND DOLLARS <br />rt100,0001.11i ADORION TO THE COO' oF G06%9011'40%, INTEREST, ATIIMOIEY'S FEES, AND flASIAOES AS <br />PROVIDED FOR IN VECTION Ma OF Tete LABOR C <br />AUTHORIZATION FOR OTtlER THAN 0-57 SIGNING PkRIMIT APPLICATION <br />c(--- ;TOti. (v• tiLlt_eek\E;._ jaionastreoledil %tensed authorized repirsemative), <br />Kt...ay authorize Want hone) C.) Sc- r - <br />to an il Sen Jonauln COW* Well Pernik Appiicalkin OP my baba I understand OW sultiortraitort Iavoile fro, <br />one (1) yaar and in blew to the work plaid doled Da the front page of flag application. <br />111413 211-071.001 <br />6112in4