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.]G6i4 <br /> x7/29/2003 10,39 2096325~-' WRIGHT ENVIRONWNTAL-' P.2 <br /> PAGE 03!84 <br /> F1LYMW Iran <br /> son Joaquln County lrmrtfnnfnants�Hglth 1D4nrartrnant unit IV Wall Parini!AMIcedon supplem,snt <br /> JOB ADQRESS: E4 101 f, . C4.49-rFX WY PERMIT sR#: -5 5 1-+(p, <br /> i <br /> LICENSED CONTRACTORS DECLARATION QW <br /> i hereby eforfn thrtt I em Ilcertsed under the provisions of Chapter g(co"roenc ing with Section 7400)of Di•rision <br /> 3 of ft 9031ness and Professions Code and my Iioense is in foil force and stfic3, <br /> I <br /> j tJoarfsa# m <br /> I'+riWtatlon Oats LO ib <br /> Data, � L� � Cantracta: 5 � 7`li� . <br /> i — <br /> Slgnrture1e: <br /> F <br /> Printed name: <br /> I -- <br /> i! WORKERS'COMPENSATION DECLARATION <br /> �E I hereby affirm under pertalty of perjury one of the falfowing dWaratiens: (CHECK ONE) <br /> I have and witf frranttaln A CutifiCS0 of ConBant to saif insum for workem'compenamUm, as provided inr <br /> by Sectlon 3700 of the Labor Cade,for vw paftrrnance of the work for wNch this permit is Issued. <br /> /1have and VIII n'raintain wcrkers'amrtpensabon insurance,as requlrW by Section 3700 of the labor t::ad*, <br /> for the perfWnIance of"e,work for which I s pamiit is taaued. **wkers'corrlpenliation lnourtsnce <br /> i carrier and pollcy numbers are: / <br /> Carrier:S)e'l Policy Number. (� _ <br /> I Certify that Ir the parlfplMwee of the work for whIM this perm#t is issued,1 shali nat employ any oersm in <br /> any manner oro as to become subject to the workers'compemadon Awa of Califumia,and eget drat.f I <br /> should became subject to the workem'cornl}ertsa' vieiona of Sedan 3700 of the Labor Code,l shag <br /> tatfrwith compiy with those provWwis. <br /> Data; <br /> Prkued Name: <br /> WARNING:FAILURE TO SECURE NrCMPMW COUPIIN,SATION COVERAGE IS UNLAtftr rUL.AND SHALL SUE JECT <br /> AN dNKOYER TO t:ittMINAL PENALTIES AND CIVIL FINES lip TO ONE HUNDRED TNQUUW DOLLARS <br /> {$I OVAbo.1,IN ADOMON TQ THE COST OF CoMpe"ATtON,IN71=011',ATTORNM FEES,AND DAMAGE!A3 <br /> PROYMO FCA IN SECTION 7ne or-TAE L4MM CODE. <br /> AUTHORVAT(ON FOR OTHERTHAN C-67 SIGNING PERMIT APPLICATION <br /> �+ {ei�ratun nfC$1'go.rasoa autltorilad nprasarn rtlwj', <br /> isurby autAamw tprint name hlfLl G h�T h�v v I X4 e- r.*-r-S£ev,ces x x. -lEpp-!*,w5 <br /> to sign this San Jaaquin Caumy Weil Permit Appttitatfon an my bwW. I urtderetand this autlrorf isdon is Valli I for <br /> �rN 11 j year*M is dratted to the work plan dated an the front page of Ws g"ilk;gion. <br /> e�a.oz1 lw <br />