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Dec 23 04 09: 09a SIF-852-9558 P• 1 <br /> 12/22/2004 10:06 l 1%, HDRIZON PAGE 02 <br /> 12/03/2964 16:41 2094603433 FIFTH FLOOR PAGE 03 <br /> San Joaquin County 9b%ironmentel Health Services,Unit LV W411 Permit Application Supplement <br /> JOB ADDRESS:,ZZSV-5eL'}Vlp"-Drt PERW SR#: <br /> CA 9 UG <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I em Gcsnaed under the provisions of Chapter 9(commencing with Sectron 7000)of Division <br /> 3 of trill business and Professions Code and my Ilcense Is In full force and ertec.L <br /> License M 2-& Expiration DaW. <br /> Data: ZContra.rr� <br /> r: �C d / rl I N En v'. ,c1 <br /> SignRtufe• 2 Title: <br /> Printed name: l <br /> WQRKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the falbwing declarations: (CHECK ALL THAT APPLY) <br /> I haire and will maintain a Cdrdfinate of consent to satf-Insure for workers'compensaWn,as provided for by <br /> Section 9700 of the Labor Cade,for the performance of Vie work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3704 of dw Labor Code, <br /> far the performance of the work for which this permit Is Isstied, My workers'compensation insurance <br /> carrier*Md policy numbers are: <br /> Carrier: k/l {�51 AJIF4- 'S".rr2_ policy Number; --> <br /> _I certify that in the performance of the worts for which this permit is Issued, 1 shall not employ any person in• <br /> any manner so as to become subject to the workers'compensalian laws of California,and agree that If I <br /> should became subject to the workers`compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply vAth those provisions. <br /> Date: Signature: <br /> PrIntod Name: <br /> WARNtidG:FAILURE TO 39CURE WORKERS'COMPENSATION COVERAGE 1S UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML,FINES tip TO ONE HUNDRED THOUSAND DOLLARS <br /> ($1 00.9m.1 IN ADDITION TO THE COST OF COMPENSATION.INTEllE9T,ATTORNEY'S FEES.AND DAMAGES AS <br /> PROVOID FOR IN /LOX SECTION 7746 OF ME LABOR GOOF- <br /> 4 <br /> ODE <br /> 1,_zJf't}!4 i-d !A"I?_ //f"�1,at' OX (Cr57 Aconsed authorizod representative).hereby <br /> r- <br /> authurw F1 tnI r LI <br /> to sign this San Jowmin County Wall Permit Application on my behalf. I understand this authorisation is valid for <br /> on>t(11 year and Is limited to the work plan dated ion the front page of this application. <br /> 5-170461 l4! <br />