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i <br /> i'dfiyk 1 <br /> San:.foaqukn Casunty'invirrmmenti Health SpIYiGeaC,unat t1/,tiVpii I?ermitAppllcataarr Suppleme:at <br /> ' .. PERMIT' SR# <br /> J013 ADDRESS' <br /> p�CL�1RAT1C)N (LC <br /> LICENSED CONTRACTORS <br /> commoncino with Section 7400)cif DIVIsion: . ; <br /> I hereby affirm that I am licensed under the pr <br /> of Che{i�'9{ j <br /> 3 of tbs F3u6trtess and Professions.Carie and my liceKia4ij is jri full force and effect. j. <br /> Expiration Date: <br /> t_lcons® S S` S7 �, <br /> E: <br /> Date: 6q- 6 2- f Contractor <br /> Sign>ikturia7 7 — •• <br /> WORKERS' COMPfr.N$ATION DECLARATION <br /> t hereby affirm undo(penalty of penury ane:of the following declarations: (CHrzr_KALL,1 THAT APPLY) <br /> I have and will maintain a certificate of oonsent to self-insure for worker$'CampOIFOOtlorr,as provided for by <br /> Section 3700 of the Labor Lode,for the perfcwmanre of the work for which alis perm(.h;ilsa; ed. <br /> and valll maintain workers`compensation.insurance,�re�guired by section 3704 of ttie� Labor Code, �.L <br /> ansatlan Insur2ince <br /> for the per ormance of the work for which this permit is laasu&j. My workers'a>amp } <br /> comer and poilcy numbers are: <br /> Cartier _.. Policy Number: <br /> ✓y� V'� `�8l/C. 2. +G QI <br /> � <br /> l Cerufy that in the performance of the work for which this permit i5 issued,I shell nnl Hrrlpla)y any person in <br /> any manner so as to beCOMe sub(act to the workers`compensation IaWR of California, and$grey that if I ' <br /> should become subject to the workers'companuatlan pfovlsions of Section 3700of <br /> the Labor Code,I shall :t <br /> forthwith comply with those provisiaras. IF <br /> Date: OV-02-0 signature: <br /> Printed Norris:, r,*0.A -� <br /> WAIRNING:FAIL URE TO SFGURE WORKERS'GompriN$ATION.COVERAGE IS UNL-AWFUL,AND SHALL SUBJECT <br /> AN elllf'LC1Ytrs!TO CRIMINAL PENALTIES AND OML FINES UP to ONE HUNDREt7 THOUSAND DOLLAR$ ' <br /> ST,AC��KIiIt:Y'S F�FS,Atilt]#]AMAGES As <br /> (;1po,000.),IN A1301TION 7b TETE t.CST or comprENSrATION.1NTF-RIF <br /> PI CWMED FOR IN SECTION 3706 OF THE LMOR CODE. <br /> I C I�7rVY�•� Yf �4dZ trC�'L1 f `' (C-If7 Licensed a►uth�ortzed ryapr�sarltati�ea},haroby <br /> to sign this San JoaquinCounty well Pormilt Application an my b6haialf. I undorsOnd thle;'authorivatlOn is valid for <br /> one(1)year and is rtmlted to the vmrk piatn.dated on the f nt pais Of this appljrattnr'I• <br /> 5-17-20001 MI ._ -- .G <br /> _ ; <br />