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07/10/02 WED 13:11 FAX 650 691 9837 SECOR 0 004 <br /> 10004 <br /> San Joaquin County Envirenmental'Health Services, Unit IV 1Ne11 P�mt3t Application Supplement <br /> JOB ADDRESS:. I� k-j '7 C, PERMIT Ski#: <br /> LICENSED CONTRACTORS DECLARATION (ICP) <br /> I heraby affirm that I em licensed under the provisions of Chapter 8 (Commencing wit), Section 7000)of Plvlsron <br /> 3 of the Business and Professions Coda and my license is in full forceand effect. <br /> License#: 7:9. 0?o-1 Expiration Data. y fWZQXA� <br /> ortractor. VAt.J l-)1`41hrIll -LnC <br /> Signature; Ti <br /> t ,,l� 't 1 / tie: (�?1.odull.cJU ..� <br /> Printed name; Jar iCj 71 V( CyXJ2J _ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of per)ury One of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self insure for werKers' compensation, as provided lur by <br /> Sectlon 3100 of the Labor Code, forthe performance of the work far whlch this permit is Issued. <br /> I have ano will moin(ain workers'compensation Insurance, a< required by Section 3700 of the labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation Insurance <br /> carrier and policy numbers aro- <br /> Carrier; __EAF)d Pollcy Number. 53-5 '� <br /> --I certify That in the performance of the work for which this permit is issued, 1 sha0 not employ any person in <br /> any manner to as to become subject to the workers'compensation laws of California, and agree that it I <br /> should become subject to the workers'compensailon provisions of Section 3700 of the Labor Code. 1 shall <br /> forthwith comply with those provisions. 1 <br /> Date: h� l�� ci Signa4tu ro:_ l(L/ ).tpi-rlLd <br /> Printed Name: �3..4.LUj. <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (51DD,Onn.), IN ADDITION TO THE DOST OF COMPENSATION, INTEREST.ATTORNEY'S FEES,AND OAMAGPO A$ <br /> PROVIDED FOR IN SECTION 3705 OF THE LABOR COOS. <br /> I, - �1t Hoerrsed uthairized represerriativel• harcby„ <br /> authcrizo L • •L-59>- <br /> l .V'Vk�2 7Gr�1. <br /> to sign this San Joaquin County Well Pent{ Application o /y behalf. I understand ^-h <br /> this auoriaation invalid fur <br /> ono�t)year and is 11mitetl to the work plan dated on the frantpage of this application. <br /> wl�ad WNl%9•q l Fr>e t-rota••� I <br />