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<.• IL <br /> Apr-10=02 11 :34A VIP' -IEX, INC. 510 `98 7679 P-02- <br /> '-2'2-- <br /> .02'-2;2-- s W00DLJFaP.D-iLYDE CONSIA?HNT `.... biLl Lri*4 J� W.Us� _or <br /> r <br /> _.. Steri Joaquin Counly Environinental Health Services,Until IV Welt Permit ApQticaffian Supplement <br /> L ,JOB AUDRESS: PERIAIT SRO: <br /> LICENSED CONTRACTORS DECLARATION (LCO <br /> t t erabjr ifirrn tha ll 1 am Foertsed under the prwAslaris of Chapter 9(Cornmenctng with See'jan MOO)of cHvisier <br /> 3 of!rye EUsiness and Prtdiewiar►s Code and my license is in full force and effect. ff � <br /> UrAnsa#: �'(� C �cpitaRiptl bite: 7 f 4 1 r7R(�;['rte <br /> Dote: i 0 13a Comrades: <br /> 5lgmaturt_ �_ �!�'�d1�a TIN*: ?C <br /> Printers nam a: �.1��-k i~� ju.J�� r <br /> WORKERS'c:OMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing dealaratUPW (CHECK ALL THAT APPLY) <br /> I have and win maintain a certificate of eanaent to seK4mv ve for ieorkW ow pensation•as pievined for try � <br /> -1700 of Ills-Lot rar(Code.forthe 3aerfon211"Of thD work for which this permit is ls3ued. <br /> _�/I have anti will maintain workers'aomponsadon iftwrdnCe,as required by Steffen 5700 of the labor Cotte, <br /> k r„r thg r,r.s r.-3rn-4rl e or the work for whirr:this permit is issued. My wtirkeW Comp ertsxltiorl insurance <br /> ;-41.'y nils hers are: <br /> ( ca+risr: U c E_ri cR_— �hS <br /> 1 <br /> I derOr 1!:2!in the perfon7iartoe of the work for which this perm it is inuad, I shelf not employ any pe in <br /> pry m+!encs.5!t At In home SU <br /> b;ect to the warkem'WMpersatlon!a"of CatifornEa, and agree khat if I <br /> sI,CL'd becorn:subiert to the workers'carnpensetter►prci%isfons of Section 3700 of the tabor Code,t shrill [ <br /> f1101-ilh v-)-nply wilts three provisions. I <br /> nat*: ' I ` 'J Signature: JL <br /> Prin led Name, ,� f2—(Slm� <br /> WARWING:FAILURC-70 SlrCVREWORKE"'COIAPENSATION COVaRACg IS UpiLAWFtJI,.,AND 9K%XL SI UAGT <br /> 1 <br /> !14 r✓iM1"OYER TO'CRWINAL PENALTIES AN1D CNTL FINES Up TO 014E HifNCRW THOUSAND DOLLARS <br /> rFt00,cs�j0.).Uf AOL:1MON TO THE COST OF COMPEN"TION.INTEREW.ATMRNEr$FEiEs,AND pAMAGES Ap <br /> SI=CTION i746 oP YHE LABOR CODE, <br /> .,.•...cvIseature eflC•57 Ilcer,sed atsgtorlsae r.p.zsrn+ativa!, <br /> to sign this Sall Joagteiil Com Will Permit AppWmiloe on my behalf. t Understand!his sullhorizatlan is vavd for <br /> onp19.J1!n!ji 1,,to the"t*plan dated OR the front�Jlp!Ottieta apptlC,1t10R. <br /> S-i •2ilitp f NIt <br /> TOTAL P.03 <br />