Laserfiche WebLink
Sent By: GeoSyntec-Walnut-Creek; 925 943 2366; Mar-17-00 9:18; Page 3/3 <br /> Sent By: Gregg Drilling & Testinonc.; 925 313 0302; Mar-14-0 :10; Page 317 <br /> Sent By: GeoSyntec-ftlnut-Creek; 825 843 2366; Mer-9-00 14:60; Page 3 <br /> • <br /> San Joaguln•County Envkonrnental Net Ith SonIees,daft NWst!'Permll Appllcadam Supplemont <br /> JOB ADMEM,121 .S►' Ahaxb?f'` PE W11 SRN-. <br /> LICENSED CONTRACTORS DECLARATION [LGD] <br /> I hereby affirm that I am kpnsed under the provisions of Chapter 9(oommencing with Section 7000)of QlvWon <br /> 3 of the Business and Profo9stons Code and my license Is in fui hmm and effect, <br /> Licensee t �V sr6 Expiirstioo Date: if ZZ I& - <br /> Date: Co !Idl: Lw <br /> o =y �!� 4 <br /> $ilgttatun: rue. <br /> Printed rtarns- <br /> WORKERS*COl4MPENSA170N DECLARATION <br /> I hereby aMrrn under penaky of perjury one of the follow"declarations: (CHECK ALL THAT APPLY) <br /> _I have encu wllf maintain a co VS ate of coneem ID self inure for workers'componeation,as provided for by <br /> Section 3700 of the Labor Code,for to per"T arcs of the Wolk for which this permit is issued. <br /> &heve wo WMI mah►tctin workers'comperwtlors Insurance,as Mquired by Section 3700 of the Labor Code. <br /> for the penbnTonce of the work for which this permit la issued. My workers'compensation Insurance <br /> carder and pol"numbers are: <br /> carrier. Popsy Number:_ 000 4 5- <br /> _I cerft that in us porkwenanca of 1ho wort for which this pwmk Is Issued,I shah not employ any Person to <br /> any nunner so as to beoome subject to the workers'oornpemwlion lags of CaGforn*and agree that If I <br /> should 6ECome subject W the wor km'corrilw tton provlslane of Section 3700 of the Labor Code,I shall <br /> forthwith wrnoy with those provisions, <br /> Date. signatu"; <br /> panted Name: d <br /> WARMHO:FAILURE TO SECt1RL WORKORW COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL.5U6JF.CT <br /> AN EMPLOYeR TO C:100NAL PeNALTt"AND CIVIL h7N99 UP TO CM N LlNORED THOUSAND DOLLARS <br /> IN ADDITIOff <br /> p;tROVICIED FOR PITO 370d OF T O LABOR COMPMATIOR. AS <br /> YW T�ATTORNErs FEES,AND DAMAGES A <br /> M. <br /> lWensed authorbmd nj�rasMtati»),tnr+b�r <br /> *LAh fire <br /> to sig»Ails tier+Joaquin County Wail Pormlt App1lctrben on my b~. I understand this nutfwrkation is valid for <br /> ons tIsar and M Ilmhed to Urn works en dated on the*OM page of Mk Ic+atlon. <br /> u' <br />