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Sar, Joaquin County nvir�tal Health fiep r arimant t)n;t IV oval. <br /> Permit <br /> ' '7.,� r n 'u, t igentai <br /> J08 ADDRESS: _ `CJii yyN�.�.�,-� PERMITS _060 1179 <br /> oho z®3 I <br /> 000 352- <br /> LICENSED CONTRACTORS DEC1_ARATiO <br /> �. <br /> W <br /> by affirm that I am lc- d cinder theProvisionsof Cha rter 9 (C rat ,g vff Section 7C�G} of <br /> her <br /> Division ? of the Dcsrnessandroiessiors node and my license 1s in full force and effect, <br /> Licence n: <br /> t i=xp hate: <br /> r <br /> Cale- <br /> L;orl petor' <br /> Siottalure: r title'. JC:r7"P�r,! <br /> I F fiat+dame:. <br /> WORKER'S COMPENSATION DECLARATION <br /> 4 hereby afflrm under penalty of perjury one Of the following declarations'(chee)(one) 4 <br /> t <br /> , <br /> { 1 have and will maintain a certificate of consent tc selr insure for Workers' Compensation, as t <br /> provided;or by section 3700 of the labor Code, for the perforsncirtce of tht ork for, which this <br /> pPrrnii is issued. <br /> i <br /> 1 have and t'y;ll maintain wo ke ; Lo npersa!)n tnetarar: e, as requited by Secior, 3700 of the <br /> Labor Code,for the perfor nancu of Ihewcrk for Whdch this permit iS issuad. My orkers' <br /> Compensation insurance cern=. and policy numbet's are: � j <br /> A,MIPtct tis u <br /> I <br /> carrier: .ST+EGI R)..Tl1 Liar Policy t:JuPnber. t._6? } <br /> tt�5u�.-�t-a" L.trMC,nnv� i <br /> ! I cenify that In the performance of;he work forwhich INS ! er9nit Is issued, i shall not cmrioy any ' <br /> person to any manner so as to become subject to the wort s' compensa'ijon jaw of Cajlfon,Ic, and <br /> agree that If I should become suo,ect to workers' compensattan provisions of Section 3700 of the <br /> Labor Codec, I shall forthwith Camp1V with'these provisions, <br /> f <br /> Exp. Date: t, 01 j C 76 Signature: <br /> Print Nance: <br /> WARNING;FAILURE'ro SECURE woexsRs'Comp NSA-nON COVERAGE IS UNLAW,UL,AND SHA,L SUFWeCTAN EMPLO'IEA 10 <br /> CRIMINAL PENALTIES AND COAL FINES UP TO 5500 000,1N ADDITION 1 O THE COST OF COMPENSATION,INI'EFES T, <br /> AVGF;YEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 8705 OF THE LABOR CODE, <br /> - I . F ZATION FOR OTHER THAN C-57 SIdINING PERMIT APPLICATION <br /> 4, 1 t -----�-� — -(signature of C5 li,eased authorize i representat)' <br /> I � , <br /> hereby authorize(print rama) to <br /> P _ , <br /> sign this San Joaquin county Well Per,nit Application an my behai . I understand this authorization is valid <br /> ;nr On�Year Prld is limited to „ _ iyurk P'Si dated uu -.nr '- nt; tg O=this epi._atifa;t. <br /> HR§ilgiMl <br />