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10-`23/2002 WED 08.19 FAX x}002 <br /> �V <br /> FEB 18 2003 <br /> ENVIRONMENT hc;;LTH <br /> PERMIT/SERVICES <br /> San anayuin County Envirr+nmenta{ Health Services, Unit til lef! �'ertr�it Appiicgtioll Sup}ilemero! <br /> , <br /> } JOB ADDRESS: � •� PFffh'lfT SFt#: � f <br /> LiCENSEO CONTRACTORS DECLARATION <br /> lieraby afi`irn7 1h-,R:l 2m licenvesl llndar t11C prGvisioris of Ch&Glen 9 (CUr3'lr'+eneirg with SMutiOn 7000)of D'.vis;an <br /> 3 of the Business and Prafession-s Code And my license i$In full force and effect. <br /> � t.iGense#: expira'fnn Date:t <br /> 1 f <br /> !_� J•t-> -1-— °1tCdGtOr: _ �11' <br /> 7ael7 1 <br /> — <br /> � Signature, <br /> Printed narno. �Jcr' 4. _ <br /> KERS' C0MPENSAT(0N DUCLARAVON <br /> WOR � <br /> I hereby affirm ,,00rer vena#ty or per)ory one of the f lowing c'0clararit+ns (Cl-1ECK ALL THAT APPLY) <br /> i —I have <br /> an�i t}Olof xfti� Labor <br /> Calder,for the perfor,cate of tm3eto {of the work or whs h ih s permit is iss ecl. far by <br /> i <br /> V/_I have end wiN maintain'sn wurxers'eomp�nsscien insurance, as rrrftlrreti by 5eot a <br /> n; 770 or the Labor Code, <br /> r for the porfo•~mance of the work for wh;10 tris permit Is issur-d. My workers' cornpensatiQn, insuraPca <br /> rarr;er and policy nun^bens ore: r t <br /> Carrier. I <br /> �' L�1 PPiicy Number: _ -- •.�" <br /> — - <br /> _ ceat in tl)a pertormance of the work for whicii this parW is iss�ed, ► shaft not empicjy any Person in <br /> Intify th <br /> f <br /> cp marnar so as to I�ecome subject tc the workers`compensation laws of California, arYd agree mat if i <br /> I should become -ubieot to the vrorkerS' cc;mpiansation provisions of Serotion 3700 of the Lanor Code, I stlal! <br /> forthw'Ith of-nply with those provisions, <br /> Printed Name-' <br /> YV,�RN?NG:FA11,I)RE TO SECURE WORKERS cprUlPeCML�S��ION CO nEUP Tj ,RAuV91�RE0 ATHOUSAND�LLAR5L,AND SHALL UgJEGT <br /> AN TiNIpLoYE.R TO CRIMINAL PENALTIES AND <br /> ` (Sd04,0aQ.}, <br /> IN ADOMON 707NE CCJSlr OF E;cwPENSATION, INTI=REST; ATTORNE-rS FEES,AND DAMAGE$AS j <br /> I PROYMEO FOR IN$i".CTI'N 370&OF THE LABOR CODE. <br /> I <br /> C-57 lits J authcrixa�d rupre89nt tivv, hcrebV <br /> iJ <br /> auS171LrlLe <br /> valid toY <br /> to`ign this Son Jd cluin County Nvefl pdmiit Appiicaklanr Omy behalf, i u+iclerStand Chic sutn�r'•tation i� <br /> ane(1 year Ar1d is ilmltta to the work plan dat@d On the fr'Ont pagtof thi<0l1plic�tion. — <br /> r LZ> <br />