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06/30/2004 09:05 91696104 ' SECOR PAGE 03/03 <br /> Lie K /( <br /> San Joaquin County Environme tal Health Department Unit IV Waff Permit Application Supplement <br /> ,0, 0/ 00 y0 Id-7- <br /> JOB <br /> ADDRESSZry PERMIT SRO: <br /> o rr �� <br /> �wwr <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing wlth Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is In full force and effect. <br /> License#: Expiration Date: <br /> v <br /> Date: aContractor <br /> Signature: L �7 a q koL%A L0— <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and wlll maintain a certificate of consent to self-insure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. <br /> _I have and will maintain workers compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is Issued. My workers'compensation insurence <br /> carrier and policy numbers are: <br /> Carrier: T�NPollcyNumber: g2y'%G <br /> I certify that In the performance of the work for which this permit Is Issued,I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws Of California, and agree that if I <br /> should become subject to the workers'compensatlon provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date:_l�-�'�`Y Signature:— <br /> Printed <br /> ignature:--Printed Name:�__ O�/f"y�✓X �a;pi`'? �_-�— <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100.000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C57 SIGNING PERMIT APPLICATION <br /> 1, � � (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) G LENT Jf�Ji�rMs 6 L ,4<V"e f'i�T�Lr�?Tf�►?Z' <br /> to sign this Sen Joaquin CountyWell Permit Application on my behalf, I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> a-29-021 MI <br /> EHD 39.02401 <br /> 9/30/2003 <br /> ZOO In euTTTTJO pJx,ep00,M 00£tt,LCLOL XVd 9E:60 £OOZ/07./00 <br />