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San Joaquin Count nviro menta Health tment Unit IV ell P mit Application Supplement <br /> JO <br /> JOB ADDRESS./!%2-6 Al. lir,? r f PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I aTI'�e� ei'tqe ? visionT0 Cap�fe�r J comn.�in�g�witFr3eeti�n 7000) of Division <br /> 3 of tie Business and Professions Godo and my license is in full force and effect. <br /> I hereby affirm 'that I am iicansed under the provislans of Chapter 9 (commeno ng with Section 7000)of Division <br /> Lice s3 of.the Business and Professions Code and my liand effect. <br /> lcEse Expiration Date, <br /> Date UJtL <br /> 6�7�&54et- <br /> Sign Contactor <br /> Me: <br /> 7'dte: <br /> Prin ame: <br /> Printed name: �- <br /> ERS' COMPENSATION DECLARATION <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: JCH�FC�K&�T&14PLp�r►, Y) <br /> I hereby affirm undef penalty of perjury one of the following declarations: Cit C <br /> _ I have and will maintain <br /> �eeio ' dC1Ofie�aL�ar¢6e�rtifico"gf eott� nt X'f <br /> � dF�C8F�4 ' I WA4W.A9r by <br /> irsgioed. <br /> section <br /> f , �fYY k RE�tlti tri Myworprgrit't,rp 1_A ce <br /> arrierj e���d1���FGb�F&are: <br /> C rrierarrier. .�,��-' _ . 4 QJ1 � p641 1 $oF ��C U ST") 0 <br /> I cert"rhfYlr � d il�R��t9fePWo1<RrM h l i' f II43i00 <br /> of ►n to an pRrlmon in <br /> e f tw RA lson n <br /> ny m B�sSfb �� I's LP% i Af �WAIM ,1 <br /> hould' tai � Sr e or�p�nsafion rovisions of ectionof the Labor Code, I shall <br /> f rthw i Tre"Isons. <br /> Hate: Signature: <br /> Date rgnature: <br /> Printed Name: <br /> Printed Name: <br /> WAMNG:FAILURE TO SECURE WORMERS,COMPENSA-noN COVERAGE 15 UNLAWFUL,MW SHALL QUOJECT <br /> WAR WGWftlQl'1E8 TO€$t�(It>i�`l �'�l�'�V� � '�RFM Iwr;XwksE T <br /> AN E Rntmt�.lydc�[AII iJ R <br /> ($100 tltsyym%bmtf#�P1'4AL�b�9 I . .N, INTEREST,ATTORNEY'S FEES,AND DAMAGES A <br /> PROVIDED T,R IN SEQ1PAkjftQIiii6iffi CODE. , <br /> 4 (G57 iicansed aulhorimd reprrssrrtativeL loerrhy ' <br /> I, i not 87th ed ' <br /> here ytar ,yn,� licadion an my behalf. I undorstand this and wia*dW is valid for <br /> 'to sig9�s( }ge�d�fldedtmtyaWulMR+ekrAlal+10.° 114 'b�i9'P'�yPBfFt�f1�8�this authorization is valid fo <br /> one ( 14MI Mimi ` f this application.- <br /> 1-25-02/MI <br />