Laserfiche WebLink
lag/08IYp b v. 0.vuv <br /> 141 1- Q __ <br /> San Joaquin I.ou nVlratin�Health ©epertmenr UhIR P Wali PermitApFlioatfan 9uppfemdt�t <br /> �.fs fis{p cPERMIT SRP o� 214 <br /> ,JOE ADDRE88' <br /> LICENSED CONTMCTORS DEC AIRATION LC4.Q� <br /> I hereby 0"that{am Ik�er"d undet the pmyAst"of Cho*i3(aurw�nwdW with SeoWn 7000)of 15 vUn <br /> 3 of flee Businaaa and pfotsasions Gods and my Iloense Is In Toros and r <br /> UrAMB r ... s-f o ra on r <br /> Dow: ' <br /> Mw <br /> �gr1�1MFr�i w <br /> Prilrted»erne: <br /> WORKFeMpEgSATION.DECLARATION <br /> I Irby afiinn w%W penafiy of pew <br /> ane of ftfolia+nfn9 dedaFatio[ . (CHECK ONE) <br /> I ttai►a VA ws mWtaIn a oertiflcata of c0n"ht tc self-l�rra tot rrrorimrW�>�'83 f��for <br /> by$pclion 9704 of ttre Letior Code, <br /> forft Farfommm nt thrt Mralic foT WhIGh tlrl6 permit iebuad. <br /> I ran am Will rn�ntaln worlcere'compennadan insuranaa,as requM by 6edon 3700 ai the Labar Code, <br /> for the pVWnVM of the Work for which fids perrr*M'WW MY workers'aampenso0on hrauaiAtua <br /> Ce w NW OWW rKft%rs are: <br /> carrlar:Al^5 ^ I V ri� Poucy Niumber- <br /> I cedilfy that in the parrorrnsnce of ttra Work far%Vhlch this pertalt iS iPWW'I ahaii not employ aft <br /> Per son in <br /> OW friww so as to become*AMA to the wcrkera'mn1Waa W wa of CaftOQ at tha Labor Godes,I�ahatl <br /> should beWo et*d to the wptkvrs'oomPensetlon Pv'skM <br /> toltwft wmPly With ih4se proVlwww <br /> Cxplrrltlon ice'�'� �lQnatura: �. <br /> Pllowd Marne; <br /> WA1lAbN�:fAll t 'r O Si=cOEIE W 4RK�Ra's 05ATNN coVMAGr to UNLAWFUL,AM VALL SU*JI1GT <br /> AN iEONPl.OYI" w CRIN M.paNAL'>'�a AM CIVIL PIltl�UP 1'0 tang Ftl!!'lbltllO I fiOt�SlINd DOLLARS <br /> ({90opt Lb 0 AMMON TD TW ETM CW COMPIRWATIOK IWM WXr.ATTt7FtMIr1[°R F103,AND DA4140 A9 <br /> pWYIM FOR IN agaMN 3706 CF TIM IASW CODE. <br /> AUTHp 4TION THAN G-9 SIGNING PERMIT APPLICATION <br /> 4 4ftnawm oft47 Ucwoed eywtlwlt wd roprewft t+ra), <br /> hereby aveadze(PI1nt <br /> to elan this fm jumpin oaaaty Well Pemalt Apphaffiloo an YW behalf. I tWAvrsfand this authartza00n is valid for <br /> erre(i)"or and is Umli ad is the Worts Mn dated an tie WA Pape of This apptlaatton- <br /> a! is <br /> e <br />