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!T E <br /> 1 <br /> --- -- <br /> } Sar:Joaquin County ,..nviral Health Department Lnst IV 4°deI? Permit C,u's►ptdner.'.. sal_—j <br /> JOB ADORES& � y�� PERMIT w <br /> i <br /> r1l�t G1J O�l� 2e63 <br /> ' l <br /> LICENSED CONTRACTORS ❑ECLARA T!ON {L'CQ) <br /> Ii <br /> I heresy of Ian that I cm liconzzd ?ender he provisions of Chapter 9 (comment ng with, Section 7000) of <br /> I Di is?br ti of iii^:. and Professions Code and my fireose, is i full force ami "J eci_ } <br /> f6 { <br /> > cense -.' 4a Exp pole 3 7(3! <br /> { l <br /> f Gate: Jam/ a�� t � __� Contractor: 12�Cis'OL �f-fM� ,th)bz=JJL <br /> Si?natre_ } - - _ Title _ v 'C } 'JOJ7 F jYAif6F j <br /> F'rintNames K j (�1� 4tk.J= tQl1 <br /> WORKER'S COMPENSATION DECLARATION I <br /> nerab,affirn ?ander penalty of perjury one:ofsthe following declarations:{check one) <br /> I I <br /> l have and will maintain z certificate of consent to selfnsurG fio•".Korke~s' compensation, as <br /> 4 provided for by Section 3700 o€the labor Code,for the p rform@.rice o the work fer which this <br /> per crit is issued. 'I <br /> I i <br /> t nave.and will maintain work.erS Go piper isat On insurance, 25 roqu red by S-rcfion 3700 Of%he <br /> Labor Gode,'fcr the performance of.ihe work for which this pen;sit is issuer', fly workers' <br /> Compensation insurance carder and policy numbers ace. i <br /> a AM;•=icicA.a it`l7'rrYL+sA�,�Nf}4. <br /> e Gar;ter: 5�EraALTt Policy Number: 6S1 i � i k_,? } 1 <br /> T Nf5v it,fw r..- -A, 64 f_.0^^mARtJvI_ ' l <br /> I Cert{ty the',in me performance of,he marl' for which this oerwit is issued, I shall not eriploy any f <br /> poison in any manner So as to become Subject to tiff lavv of tvamornia, and � <br /> 2Gre.- that if I Should become subject to workera' Compe rsalion provirrons dr SECf!orS 3700 Of file � <br /> Labor Code, 1 shall forthwith comply With'those prcyisions. <br /> 3 <br /> Exp. Oate: It,3171 L. aiy Signature: 11 <br /> i <br /> :Print Name: ��,�-1J L?Y'r !�KP^rVFtl iri.:ty <br /> ;r <br /> t <br /> Y1e:R"n'iNG:FAILURE TO SECURE WORKERS COtiPE7<Sa'nON COVERAGE IS U17LAYiFk;L ,f.NO SHaLt SUP.,IEG7:AN EMS'LO'r"£!t TO l <br /> RrMINA„PEYA4'TIE5AND CIVIL FINES UP TO*1111,0111,iN ADDITION Tp'ME COST OF 1704tPENSATION,.iNTERES T',. { <br /> ATTfleNEY'S FEES,AND GAMAGE5 AS PROVIDED FOR IN SECTION 270,505TAE LABOR CODE, <br /> II <br /> -�UTMQ, 'p,,�ZATION FOR OTHER THAN C-57 SidNitdG PERMIT APPLICATION <br /> ��1{ r, ?' <br /> --'— -- {Signature Of G 67 I veRsLd�OaJthorr�e • represuntat��e}, <br /> 3irthortze{print name �) -�v'�t -{- - .to <br /> j <br /> hereby- } _ _ <br /> j sign this San ,eoaquin county Well Permf.Aorriicatlon or,my behal'. 1 understano this authorization is valid <br /> ( nr ono veaf eod is limited W the work plan,deted or: the front p+q-�of this applica-6, n, <br />