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MAY-05-2803 16:57 URS CORPORATION 510 674 326E P.02i02 <br /> E FiE�c�, <br /> San Joaquin County Environmental Health Department Unit IV Waif Permit Application Supplement rtY 0 8 Z003 <br /> JOU ADDRESS:_ S-Q AfA r' PERMIT SR#I 1 <br /> iM RONMENT HEALTH <br /> LICENSED CONTRACTORS DECLARATION (lam} <br /> RMIT/SERVICES <br /> I hereby affirm that I am iicer,3cd under the Drovlslons of Chapter 9(cammenGng With section 1000)of Division <br /> 3 of the Suriness�a�ndd fotes4jon£Code and my ti,:ense is in foil force and ctf=. <br /> L j <br /> Liccnee 0: -" 5 5 5 ro ERGrrabon Date: 1--� /— D <br /> trale: <br /> 5- �p^ 49 J Contlsetnr: G C-X 1 D 0 k] -- <br /> Signature. // Title: r <br /> Printed name: S'D n n e r--f <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under pon3t(yof pvqury une of the fallowing det1ar3t1QnS: (CHECK ONE) <br /> X _1.hav0 and will maintain a certificate of consent to self-Insure for workers'compenaeticn,as P, ided for <br /> per Section 3700 of the Labor Coco.for the pttrformance bf the work for which this permit is Issues. <br /> _I have and well m�'ntain workers wlrpPnsation in3urance.36 wulred by SQctio,,3700 of the Labor Gode, <br /> for the De TorTmnce of the.\-,urf,for which this Dcrrnit Is Issued, My wurkerc'compensation in a ce <br /> carr1gr ane policy rnimbers am: <br /> Carrier: _ Policy Number: <br /> I CQIVy that in The performance or tnc work for which IruN permit,is iz3ued, I eholl not ompioy any person in <br /> any manner so as to be oma subject to thw workers'compen3aticn laws of C711foTn1a,end-�;t6ree,That if, <br /> should become:ub)ect to tha workers'compensation provisions of Sedinn 9700 of the Labor Code, i Chan <br /> forfhwitn comply Wirh thusc proviaion3. <br /> Date: SISnature: <br /> Printed Name: <br /> WARNING:FAILURte'tU JEcu1¢[WORKERS'COMPENSATION COVIRAnE 19 UNLAWFUL,AND SHALL su8JECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE,$Up To oNk HUNDRED THOUSAND DOLLARS <br /> pODED ADDITIC)d TO SECTION HE OFT r- R <br /> COSTCOM EGdDE.ON,INTCItE3T,ATTDRNEY'6t <br /> FtS,AND DAMACSP4 AS <br /> ROVIFOR <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> _(signature ofc.4T liunsed authorizra roprvsonallvsb <br /> I, <br /> hereby authorise(print name) <br /> To sign this Sen l00qut^Count;r Wrll PerrttltAppllution on my hehalf. I underytend th,rewall for <br /> ono(1)year and is llmitsd to tt+ri W oTlt,Klan dated on tho trOnr pilo..of thio ap01Yo0tien <br /> S•?9.02!Ml <br /> Ee 3EnNd 2J00-i� Hhi� EEPE99n60Z oD:PT E04Z/SB/90 <br /> TOTAL P.0_ <br />