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JUN-22-2804 15:11 CAMBRIA P.03/05 <br /> Jlpf-is-2804 12.23 CAI4BRIR <br /> Sten Joaquin County E(Mronmentel Health Department Unit IV WON Permit Application Supptanient <br /> JOB ADDRESS: _ PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( GD1 <br /> I hereby affirm that f am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the ausiness and Profassiona Cods and my license is in full ford and affect_ <br /> Liconaa#: C-17Expiration Dab: 1110W Id <br /> t r <br /> Data: A7 Contras r. rlop 01% <br /> ` <br /> Signature: Title: <br /> Printed name. F <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 Inereby affirm under penalty of perjury one of the foliovAng declarations. (CHECK CNE) <br /> I hal a and W19 maintain a rertifiicatc of Consent to s6ff4nsLra for workers'cOMPOnsativll,as provided for <br /> by Section 3700 of the Labor Code, for the Clerk mance of the work for which this permit iS issued. <br /> 1 have and will maintain workers'compensation insurance.as required by Section 3700 cf the labor Code. <br /> for the peftnTa we of the work for which this perri*Is issued. My workers*compemation Insurance <br /> carrier and gooey numbers are: <br /> Carrier: ,lir�• policy Number. 'ZW <br /> I certify that in the performance of the work for which this permit is inued,i shall nal employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California,and a"a that if I <br /> ghgVld become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall <br /> ferlhwith comply with these pia►rlsiane. <br /> expiration Date: Go signature; Q.29& <br /> Printed Name. <br /> or <br /> WARNING:FAILURE TO SECURE WORKEW COMPENSATION COVERAGE 18 U"WFUL,AND SHALL.SUBJECT <br /> AN V PLOVER TO cmWNAL Pt NALTIE11 AND CML FINES UP TO Olrle HUNDRED THOUSAND DOLLARS <br /> PRONIDEA,IN FOR O TO THE <br /> 6 OF THEF come CODE. <br /> AUTHORIZATION <br /> INTEREST,ATTORNEY'$PKES,AND DAMAGES r S <br /> AUTHORIZATION FOR07��R THAN C-57 SIGNING PERMIT APPLICATION <br /> h. ::M;e_4&JTe 60& _ - (signature afGbi licensed autlhorlted nepresdnhllaej, <br /> hereby authorize(print name) Laa iAsp(,{�o�-fc4�,,�,r r..L:AAA, r,r " . <br /> Eo sign this San Jaaquln County Well Poneit Appoestion on my behalf. I undwawnd this authorisation Is valid kw <br /> one(1)yser arid is Ilmlled to the work plan dated an the froril page of this sppiicatlan. <br /> 8.29-0 1 Ml <br /> EIM 2"2401 <br /> a -d nn7p I '7r? ,41::w l else "Mr :S 46nnp CT Unr <br />