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f <br /> o <br /> Nompe <br /> San 40aqui my Envi �R77't:ntaJ Heaiflh 30micae Unit IV elf Perm .A¢pAeadon, $eppmMetrt <br /> JOB ADDRESS_ S25 /V. Q GC C — PERMIT SF4P00 <br /> - <br /> ©o N� <br /> UCENSED CONTRACTORSDEC�.ARAnoN (LCD <br /> I heresy aflt rn hist i am licansed under the provislens of Chapter 9(comrnwxsng with Section 7WO)of Division <br /> 3 of the Susinesa and Prafessians Code and my licwse is in fish fameffe <br /> and cct. <br /> Llcwse P 5-lo41)� .,..._". ExpirMtlon Date: <br /> owe; <br /> slgnaWr+o: ALTom: 0 'v <br /> Printt*d name: - <br /> WORKERS'COMPENSATIM DECLARATION <br /> 1 hereby affirm under penalty of penury one of the following declarationa: (CtMCK ALL THAT APPLY) <br /> I have and will maintain a 6e lftke of ronsent to aellAnmxre tar workers`comparnallon,as provided far by <br /> Secbon 3700 of the Labw Code,for the pertarmence of the work for wh)d1 this pettMd is issued. , <br /> I have and will maintain workFrs'compensadan insurance,as required by Section 37OG oft*Labor Code, <br /> for the perfnrmartca of the work for which this permit is issued. My workers'wrnpensation insurance <br /> carder an�dlpolicy nnumbers are: 1 <br /> Carrier... 1 1 I C � ,;� Q Polity tJUMkmr. l A-)C_�3/ r- 0 lU0 ..^ <br /> I cartlfy that in the perforritw cae of the work fcr which this permit is issued, I shall nal ernpicy any peman in <br /> any manner so as to become subject to the vMor$mn-compensation tour* of Califarllta,and agree that if I <br /> shntW become subject to the workers'eompanaatim provisions of Secdon 37100 of the LAbar Cade„I shall <br /> forthwith comply with those provisions. <br /> 13ab' $i�r1�11f'a: <br /> Printed Name: <br /> WAF34NQ FANLIUR!E TO SECURE WQFQWR3'COMPEhISAIM"COVFJ;tAGE 13 UNLAWFUL,AND SHALL SIEJECT <br /> AN EMPLOYER TO GRIMINAiL KNAL77ES AM CML IM$UP To ONE HUNDRED TI!IDUVVAND DOW= <br /> (St 05,000.1,IN ADDITION TO Tutt?COSTOF CONI ENSATM,IWMREST,AtrORNEYS FES.AND DAMAGES AS <br /> PROVIDED FOR IN 3ECMON 37roe OF TW LABOR CWF— <br /> t, i C.-h7licensed authartted nWr*s0ftlJ" ,lxrsbY <br /> nudroredr t n i Q.► i e—,, &I rqw � <br /> to*ion*Is Sarr Janquin Caunty V& 1 Permit Appft ion an my behalf. I Understand this aut1wrized R Is valid title <br /> 900(1)year and is&Wksd to the work plan dolad on thn tmnt pwge of thL%appittsdWl, <br /> a-�T-;cotre r let <br />