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TSan lr agtitn Govnty 1Enviroerm8r1td1 4iealtF3 8erviceb,Uhl IV W@li 1">~T1T11t I�p>iyllCfltEOs�$L�tplurneRt <br /> �. <br /> PFF(MIT SRS'. <br /> JOB ADDRESS: �G' <br /> i Z�C�ORS <br /> LFCENSED CONTDE LARATION <br /> I hereby effirn',th,9l I am iieensCd LMIJ13r trTv proVisJorrs of Chaste 9 fCuMrlerrcirg with Se�ts4�T 7000)of D{vtsron <br /> 3 of the Business asTd Professions Coda;lnd rfly license is In full orce and errect. <br /> Expiravon Date: <br /> License#: OI0�C� <br /> pate:_ an radar: <br /> slansture: <br /> printed nam#:. I <br /> WORKERS' COMPENSATION prC[.ARAI"tON <br /> I hereby affirmunG6r Penalty of penury qnG Of the foliawsng r Acl THAT APPLY) <br /> rabons• (CHECK ALL I! <br /> I have and will, rr.aiitain a cArtlficate of ebnsent to se;f-}nsur fpr workers' cornpensatioh, as provided far by <br /> section 37oo of the Obor Code,for the peeorrrvnce of the arh far which this permit l issued. <br /> V I have cnd will maintain w4jrkers'CQmPCrnssrivn insurance, rrquired by Section 3700 of the Labor Cody, <br /> for the pCrformance of the work for which this permit is issu .d. My workerH' compensation insurance I <br /> carrier and policy numbers are; <br /> Policy Nu bar: <br /> Carrier: �- <br /> �_ .�.��. <br /> I certity that in the performance of the work for whicl) this p rmit is is5>.:ed, 1 shall not employ any person in <br /> �w c4ny manner so B8 to become siabJeCt to ttie worker&'comp nsatlorl laws Of Callinrnla, and agrvs that if i <br /> snouid become subj"to tht workers'compensations Provisions of S".flan 3700 of the tabor Code, l shall <br /> t j with those prcwisipns, <br /> � <br /> forthwith fUlrrP Y� r <br /> / �� gigrTatstrtl <br /> Date: <br /> Printed Name' <br /> GE IS <br /> WFUL,AND$HALL <br /> WA�MPL0 LURF. TO SF-CURUYITR TO CRttilr N,4L PENAQLTES DO YptL F NQS}�PCO ONE HuKoft;DSHUUSAND 95—DL.AR5�B3 CT <br /> AN 1: <br /> S'I00,1PLQ 1N Js:CA Ci IM N 7NE PENALTIES <br /> CiST OF CUNfPEN3AT16N, JNTERE°r; ATTORNEY'S l�rES,AND AATNAC:E9 AS rl <br /> i d LABOR CDD15. <br /> �� Pft0Y1dED FOR IN$ECTI,N 3706 OF THE L <br /> 47 Ilcs rrj authorized reprosont tiYe, Hereby <br /> vu[twriie -- <br /> to sign this San Joaquin County Well Fermi[AppIicatton nrs r+Y ahalf. I u�i[lerstand this�uttlor3Zatlon is.valid SCr <br /> ybng�� yg�r grid is llrettd0 Latt1C'+�rk pl8n <br />