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8-13-204 2 56P1 FROM P. 2 <br /> �CJ�!!" - Grcani :'erg r+r Myst; PH0NC N0. Sa 2004 03:13 7 W <br /> San Jaaqufrl ouniy nvlrQnmentaP Health I}eparts erlt.iJnit 1V WOI per,-mt Appficats'on SvpPtement <br /> j08 ADURESS;__��1 PERMIT SRm: <br /> i Lodi <br /> ILICENSED CONTRACTORS DECLARATION j <br /> P h9rc-bY Sf ltm that;am Iioenm-d Undw'V:e firoviS;OAS of Chaotcr 9{cvmrr:encittC vritr, sccticn 7000)of f?rVi=iar f <br /> 3 of ft-Scsines$and Prcf#ssions Ccce and my iCL�ma is in field force rnd effect. <br /> 02ic <br /> Printed risme: <br /> WORKERS, CC7MPENSATJON DECLARATION <br /> d tiatsay Ofir 'a under.penalty of pet_ry one or the fcPlowrir decWE' ns: CHECK ALL <br /> THAT APPLY)t <br /> I hBVe and.xriii m Ej rtmin a.Ue'viza'e Of c3n�Ie'It to.se f-htsare for workers'rcr tp� ,r,,a5 prnvi:Ed!or i <br /> _S Ssttion 3700 of the Lebon.Code,lar thc-Pe:��rr wnte of ttve�work for wftich tjt �y <br /> s,:e'i;.rt i3 is ued. <br /> Z'have Find will„rr i- taro workivs,compens R e1, rt�ace S rSq(1ir by eta.^L"rE +�7of Oef ebtr.CnC . <br /> fcr b*pa cr11'VC9 of.the work for v�l*h this rit mit 1s issQed, MY Yiorec:�s'CQ- <br /> f tarrial and poky num/ers are: �- �tlan irzs r,dn„� <br /> Cm Friar Policy Number: i 5 lvx6s"� <br /> i i <br /> CE,'tlfy thiit in Ple perfarm2nCQ Of the"rk fbr whici;ttls:perrtit is iGsugd; P s:7ePP f"Ct tr^1}i4Ly7t any 17Ers4.`:in <br /> any m;=rinef sus es to become Subject to th*WCyriigr—z'G*mPerllation 181Wv5 of callfc'mf”-znd� a t <br /> _ S'lo tld became$:sbi ect to thb wcr ars'Compe"S'ztitn provision$ Of Se';V 700 of the Lobo Code $6 f aiP <br /> forthwim=mply with ftso provisions. <br /> r <br /> Signature:Printed Name: <br /> 4 <br /> W.gMING;FA1LURL'rO UCURE VVORXZRV C0MF ffNSAT1O?4 C0Vm7AGZ 15 UUI. WFUL.AND.SHALL,Sd,BJEC' ' <br /> i <br /> AN EXPLO'MA TO CRIMINAL,PEAVAL,Tit:S,AND CMiL FINES UP TO ONE NuNoPte!D T140USAhq OCL'LA1 <br /> ('"00.000 i,IN AO(ltTIONt T'C THE.,OGST OF C0mJ*ZtN3AZ0K tNTEXZST,ATTORNEY'S FEM-AHED OAMAGEs As <br /> FtOV DF-D FOR IEEE•SECTION 3706 OP.YHE L.ABOR•COCe. <br /> fir~ <br /> (rignatuxa efC--i;7 licexrscd zuMvrired repros.axtit4ivc gf"f <br /> t >tit;ebyauttarize(px3nLrrarr.Qj r+� n 3 <br /> t:sign thix San Joaquin County W011 Permit Application on rr,y behaif. 'ur.dsrs:and Rl is a�ttrarEzatia I i:,valid tGr <br /> ane 0)mr Srna is llrrrPted to tho work Flan.datocf On the front Page cf this appstcar,or:, <br />