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RECOWED <br /> OCT 0 2 2001 <br /> ENVIRO�` :r��,; <br /> Son Joaquin County Envirorananta(Hoalth Servi ws,Unit 1Y W411 Permit Applic ftlgt,"i <br /> r <br /> t JOS ADDRESS:' PERMIT SR#:,.,_ -., <br /> r <br /> w i <br /> t <br /> LICENSED CONTRACTORS DECLARATION (SCD,) <br /> l <br /> 1 hereby affirm that 1 am licensed under Ih0 provislors of Chapter 9(COrnmencing with Sectlon 7004)of DMS)on <br /> 3 of the Business and Professions Code and my Iicenso Is in full face and effect. <br /> License : evirstion Date: rlt 01 - <br /> Date: <br /> .3_Onto_ Contractor 1A/ _ <br /> Signature: title:_AztA/ <br /> Printed name: ,3W <br /> WORKERS'COMPENSATION DECLARATION 1 <br /> !-hereby affirm under penalty Of perjury one of the following d0ar0ons, (CHECK ALL THAT APPLY) <br /> I have and will ntaintain a cartVrcats of consent to selFlnsure for workers'compensation,ss provided for by <br /> ! N SaWw 3700 of the LsboP Code,for the perfannance of the work for which this permit is issued. <br /> I bm end will maintain worksra'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this pwme is Issued. My workers'compan"UW insurave <br /> carrier end gra ntu»taaw are: <br /> � t <br /> a �g t <br /> Carrier iv , policy Number. �i? t _^ t <br /> I codify that in the padormence of Ute work for which this permit is issued, 10811 not employ any person in � <br /> any manner So ss 10 baane suojed to Ste w0fkero'0Mper>ftn lows of Cailfomle.and agroe that!r I <br /> shout become subject to ft workers'compensation proftions of Section 3700 of the Labor Code.I Man <br /> foretwith comply with those provislons. <br /> Oate: Signature: <br /> Printed Name: .� <br /> WARN NG:FAIUM To SWuRB WQRXBW OOMPENS"Oft COYERAON 18 UNLAWFUL,AND$MALL SUSJgC7 <br /> AN 151104-Mit TO Ct NAKAIL PENALTIES AND CML MM UP TO ONE HUNDMW T"OUSAND DOLLARS � <br /> {stDt1,060 j�IN ADDITION TO THE COST OF C011WENUTION.INI'lMST,ATTORMY'S TEES,AND DAMWES AS i <br /> PROVIB D FOR IN SECTION 3106 01F LAWR CODE. <br /> L L ef�]�rra• t✓ Ems[ (C-571teansed ed repCssRnta6YR),hom4y <br /> authorize <br /> to 6190 this Sar Joapgin'Cowrty Watt Permit A001clition on my behalf. I understand tt►tat ikuthoftatlan is raid tar <br /> Oft(1)Yew and is lirrdtod to rho work plan dated on the front page of this app.lcation, <br /> 6�17.20g0/MI <br /> a <br />