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V Mai - 13 . 2003 11 : 22AM U EARTH TECHNOLOGIES No - 3098 P . 6 / 6 <br /> . . , Aa FAY 002 <br /> San Joirquin County 61111iranmenc Health servlcea , t)h 1 Well PeuieApplicetian supplernent <br /> JOB ADDRESS ; t p�Rtlfll"I 5�2C1t — <br /> LICENSED CONTRACTORS DECLARATION (L-W) <br /> 1 hereby aifinrt that I am lioeased under the provisions of Chapter 9 (comrnwr7ring with SOpfion 7000) of Division <br /> 3 of the ©usiness and professions Gods and my license Is In full farce and effect. _�.- . y — <br /> License i!' IX 7 Expiration Date, Y� <br /> DOW; � ` ! � ontraetor: VII <br /> signature; Title: <br /> Pdnted name: - <br /> WORKERV COMPENSATION DECLARATION <br /> I hereby affirm under penolty of perjury one of the following ded®ratione: (CHECK ALL THAT APPLY) <br /> I have and will maintaln a certificate of consent to self-Insvre for workers' canlpensatlon, as provided for by <br /> �f section 3700 of the Mbar for the performance of the work for which this permit is isaued. <br /> X/ I have and will maintain uvorkers' campcns3tlon insurance, as required by Seation 3700 of the Labor Cede, <br /> for the Performance of the work for which this Permit 's issued. My workers' cem"cneation Insurance <br /> carrier and policy numb '. <br /> numbers are <br /> be <br /> carrier: �.__C__t t. i ` l ,,. Policy Number: Alt!;: - (A <br /> 1 certify that in the performance of the work for which this permit is ihsued , I shall not employ any person in <br /> any manner so as to become subject to the wetkprs' compensation laws of California, and agree that if I <br /> should become subject to tho v/orkers' compensaticn provisions of Sflation 3700 of the Labor Code, I shall <br /> forthw h o ply with thou® provisions, [ ^� <br /> , 04 <br /> bate: —.__-_...,a <br /> Signature ; I�/� rt /1�i3�rly� / <br /> Printed Name: <br /> `VRF TO SECURE NAL PFNA4t ES AND CM AL FINES UP TO ONE HUNDRED THOUSAND I <br /> AN *MPLOY3=RYO MMISUBJECT <br /> oj IN AVDMDN TO <br /> SECTION T7os O THE LAt30R COMPENSATION, INTEREST, ATTORNEY'S FEES, AN <br /> PROVibA DAMAGES AS <br /> 1 _ C37 iia/need Pura priso�n repfCSCntaflv0), hereby <br /> Pudronte <br /> IICPtIon on illy behalf. I Understand thio eureoriaation is valid for <br /> to ►Ign this San Joaquin Ceunty cash permit App <br /> ane (1) year and is limited to the work plan dated on the front age of ihl¢ n Ilcatlnn. _,,,_ <br /> WUM,-1 Wvv�.r U l Gtib I -• VOQ '. <br />