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11/27/2001 13:41 2094671' "'4 AGE STOCKTON PAGE 02 <br /> ti <br /> san,Joaquin c4uky lErMMAMerntal Health 34rV$C*So unit lY Well Perrnif;Applkel 0Wz4P0vM; J <br /> JOB ADDRESS: PERMIT Siem: <br /> LICENSED CONTRACTORS nECLARATION (�,,,,CA.) <br /> I hereby aMrm that I stn licensed under the prnvislans of C13413tet 9(0"misrecirn9 with Sat•.tion 7600)of Division <br /> 3 of the Business and Profwslons Code end my"rive is In full force and effect. <br /> License al 6- 0 Exptration Date: / <br /> Date: "'" CnntttOC C a. G <br /> dI' <br /> itgnat►rre_ 7'itie: AC . <br /> Profited name- Q Q f� <br /> WORKERS,CoMPENSA110N 09CLARATION <br /> I riereby afPlrm under par*V-bf WI Y On"of tn•fallawimg delle Wrig: (c"ECK ALL THAT APPILY11 <br /> _i have and wi11 malrtaln a ceMoake of consent to self-Insura for workers'ooMpensslian,tis pmvided free by <br /> f Section 3700 of Ulm labor Code.for Ohs Deftmance of the work for WhIcP I"iS PWMR It Issued. <br /> ]� 1 have end will maintain workers'compensation insurance.as roqulteOy Seclb�00 of of the Lew Code. ; <br /> I <br /> for the"rformanre of the work for a+hleh this permit is*sued, Myw <br /> cerrigr and polity nuenbOrs a�re/: J� �,/�� <br /> Carrier:kl aS�C !l Q M Policy Number. �._ r .5 � �. <br /> _I certify that in the verfiwmance of then work for which this permit is issued.l shaft not en►pioy ar+y Paf m in <br /> any manner bo as to becwne sulajsal to tha worker's'gorng6Asation lav'►°of Catifornia,and 90ras that U 1 <br /> should become subject to the worksts'compensa6ar+Prnvisirs sett 3700 of the Lobor Code,10all <br /> bAhw lh Complywith those provisions. <br /> Date, 7 3-t 0-/- <br /> Printed <br /> / Printed Name: <br /> WARMNO:FAILURE TO SECURE WOA IR"'COMPENSATI COYEM1A31r i8 UNLAWFUL,AND OLLA&HALtlitisdl!ItiT <br /> AN E,MpLoYER To CRIMINAL.PENALTIES AND 01VIL FINES UP'TO ONE HUNDRED TNOLSAlAtt1 I�OLiAR8 <br /> Stall'DEDtIN FCN ADDITION TO HE COST OP 4C TNR t./RB�DR COt}E*N,INTEREST.ATTQRNEY`JS ftO.AAI>S DAMAAi�S ills <br /> pmoV <br /> I tc-&7 Iicented authoftact reprrseoflt1w),hereby <br /> aythartss <br /> to,rlgn thisBan Josquln County WWrl1 ponnit Applftaoel os roy behalf t understrfnd tNs 0110~64 is wild for <br /> ort(1} <br /> your end Im tinAWO to the Warts plan dated w the front page of this 4000 0t1w- <br /> 5-97.,2od011�11 <br />