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Ser:.lowgvin County 01vir:,nmental Health�epartmentt,'n t!V St10 Perm;tagy '�n�uw mental <br /> JOS ADDRESS: _ �, PERtnIT S V 60 t f <br /> YYl(Jl 1 — o. o 2-a 3- <br /> LICENSED CONTRACTORS DECLARATION (LCIS} { <br /> I hereby ai`ffIr that I at Iiv£ under the provismns of Chapter 9 (comnzencirig with Section 7000) of <br /> �- Division 3 of the Susiness and Professions Code and my license is jn lint"Ofoe'ai '. eiffecL � <br /> License ' ® Exp Date1/-41 <br /> 2,012– <br /> Cate__. _J�/ ��1L —Comfo tor. f2Y G 51 ?rJ awl �J fr. _ + lir <br /> Signalure: Ti ie: _ CL3 7 J 7 h✓AA1r;{ � ° <br /> k ! <br /> Faint Name <br /> WORKER'S CON PENSATiON DECLARATION, <br /> hereby affirm under penally of perjury one Of the fellowvig 9eclarations. (check one) <br /> I have and will maintain a certificate of consent to sel*-insure-for workers'compensaticr, as <br /> rrovided for by section 3700 of the labor Code, for the performance Of the worn for which this <br /> t <br /> pen-nil IS issued. i <br /> 111{ i <br /> t +F t <br /> �` i 11aVe aha 4,rlll tints{i5taln WOtkG'fx uO,trpehsattort inSt)rpnCe, as ft?{jUi ed by .`=..eC!iOti.'f��,(7 Oi.h8 <br /> Labor Code, for the performance nTthe work for which this pernill is issued, Nly workers <br /> compensation insurance Garrief and policy numbers are. <br />! f ' carrier: SPaAArt�_e }J?��� Policy Number <br /> lNSvL T 4 & AA-N1 <br /> I ce nFy that in the performance of the work for vtnich this Permit is issuer!, I aha{l not employ any <br /> person in any manner so as to bef-ome subfec!In the workers COrriperisa'•.lon lata/bf California,237J j <br /> agree that if i should become subjectto wot*ers' oompensation pmision<_of Section 3700 of the ! <br /> Labor Code; i shall forthwith comply with those pro isicns. <br /> 3t <br /> Exp. Cate: Io 1,�'�! LG�t t? Signature: <br /> i <br /> fl .Print Name: L'!�tf'�• .-i{1=> r11f�t3F2.(', j <br /> V4:R4lNr:FAILURE TO SECURE WORKZR5 COi;FENSA-7I}N COVSRAGE IS UNLA4YFUL,'A?40 SH t_+. SUE,IECT AN EMP..:..OYE.^�T4 1 <br /> CRIMINAL PENA01ES AND C"V7L FINES OF TO£500 000,IN ADDITION TO THE COST Or COMPENSATION,INT`REST. l <br /> } ATTORrIEY'S FEES,AND GANIAGES AS PROVIDED FOR IN SECTION$746 OF THE LABOR CODE, <br /> It 'ii�77 <br /> '(?ATION FOR OTHER THAN C-57 SldNING PERMIT APPLICATION l <br /> t <br /> (signature of„7 C .ene authorize, reprasentatj+tef, <br /> hereby a�ifticri�e{print'name, '\ <br /> 7— l <br /> sign this San Joaquin county Well Permit-Application ort my behalf. :understand th'ss authorization is valid � <br /> i mw ona a.,andis I„n.tec aO 11hework.War,datcd oi. .;?e :tont.pagev:this ppiicatwcn. <br /> £✓ria.. .::`J:,- ,YT-...'.L£5r ...._ <br /> I <br /> IF <br /> I 4 <br />