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n rratK.lt i 3�QQ / <br /> 97/23/2003 10:39 299@32: l°'2 <br /> WRIGHT ENVIROh1YENT,g1,� PRC3= 93/04 <br /> F1 L Liv <br /> Joaquin County Envfr*M"*nW Hs*Itp D&Prb"nt Unit IV V11*11 Permit Appk*don Suppiem ant <br /> JOB ADCRESS: 14 I'' f- . C4.4X-11i54L Wray PERMIT SRP. t5—/��{-~ <br /> LICENSED CONTRACTORS DECLARATION QW <br /> I herby*MrM tf1*t l em licensed under the provisions of Chapter 9{cOarnoncing with Section 7000)of Di•.risian <br /> 3 of the Suslrtess and Professions Cade and my lioense is in testi foroe WA effect, <br /> l <br /> incense# 194 _i=xpiraticrr Calle ff ���� 0 <br /> Date: �( C.antractcr: q �.ri'L . <br /> i <br /> Sigrtstwd, te: <br /> Printed name: <br /> WORKERS'COIIMPENSATION DECLARATION <br /> hereby aRrm under penaltyet penuryono of the following looembens: (CHECKONE) <br /> _I heye and will maintain a esn4caft of consent to soif4rwure for workers'compensatlen,as Provided ivr <br /> by Section 3700 of the Labor Code,for Vw perbmuwwA of"work for which this permit is Issued. <br /> we and will maintain wm*arW cornpensadon insurartrs,as raquirW by Section 3700 of t w Labor <br /> *the performance of the work for which this penult is issued. My wooers'campansation(nsuranos <br /> confer and podfcy numbers are: <br /> Carrier. . 62S Y)-2 Potley Number.... <br /> I cerdfy that in that pedonttance cf the work far whin tris pefrnK is issued,I shalt rot employ any pew;n in <br /> any martfter ac as to be=e subject to tete workers'compema tion taws of California,and algm tttat.f I <br /> me <br /> 3hoWd becosubject to ire wortters'ecmrrsa pevisions of Section 3700 of the Labor Code,l sholi <br /> forthwith comply with those provisims. / <br /> Dale: Signature►: <br /> Pr%tedNamef: <br /> WARMNO:FAILURE TO SECURE WORKERS!=WPINSATION COVMACLe IS UNLAWFUL,AND SHALL BVEdECT <br /> AN a MPLOYt:R TO CRIMINAL PENALTIES AND CIVIL FWES UP Tp OME HUl1 DKW TMUSAND DOLLARS <br /> +3100A90.j,IN AOOMON TU THE COST OF COMPeS3ATICK INTfeR69T,A7MRNEY'S FEES,AND DAMAGEAa A3 <br /> Pf N IOED FM IN secriow?706 OF THE UU10R CODE. <br /> AUTHORIZATION POROTHERTHAN C-57 SIGNING PERMIT APPLICATION <br /> I,,�.,�/,�,�` _ Isa�tu r!e(CSI ttaerr�d arltllsttiad tsprsaarn.Tdtis}, <br /> iHnby auptorts*tprtnt neunrl 1�lRt G i♦T taw,r'r a>� 1E,a.�Tii4 L SAP-vices X - –�!EFr'-t rr. S <br /> to sign this Eon Joaquin County Wet!PrrrNt Applicadon an my beflf. I undanstm d this auxtmrizirl2 a is vslO I for <br /> erre <br /> 11)year and is orated to the wade plan dated an the front pubo of tMs sgF1laatloe, <br /> { <br /> 8-•G21 kO — --- <br />