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Mar . 13 . 2003 11 : 21A ,'vl C � EARTE TECHNOLOGIES No , 3098 P • 4/ 6 <br /> San Joaquln CountyEnvironrna``nttfttpa ih servieev, Unit 1V Wait Permit it Peit Application Su <br /> �� /� ppterrsent <br /> JoB ADDRESS : � UJ " " = PRMIT' SRlF: <br /> LICENSE CONTRACTORS DECLARATION (L9P) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 9 of the Rusineess and Prno/fessions Gode and my license is in full force and effect. <br /> r <br /> License #: i E74pireiion Date: <br /> Si9netute: Tltte: iiey <br /> Prtntod name- <br /> WORKERW COMPENSATION DECLARATION <br /> I horeby affirm vrder. peralty of perjury one of the following declarations: (CHECK ALL THAI APPLY) <br /> I have and will n alhfaln a certificate of consent to self insure lar workers' c0MPensation, as providad for by <br /> Section 3700 of the Labor ode, for the performance of the work for WhIth this permit is issued. <br /> I have and will mainteln workers' compensatior insurance, as roggired by Section 3700 of the Labor Cdde, <br /> for the performance of the work for which this permit is istovod . My workers' compensation insurance <br /> carrier and <br /> pollcy numbers are: <br /> Garnet: .2 Sl f �1 11 � _. - Policy Nurabev _��, " D) <br /> ,�� <br /> I certify that in tho performance of the work for which this permH is issued , l shall not employ any Person in <br /> any manner so as to become subj0d to the workers' campensaGon laws of California, and agree Vial if I <br /> should become subject W the workers' compensation provlslons of SA�vjon 3700 of the Labor Code, 1 shall <br /> forthWlth qomly with those provlsions. 1 <br /> Vat s: 9igneture; ' ` int <br /> Printed Name: <br /> WARNING; FAILURE TO SECURE WORKERS' COMPENW19H COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINNS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (l11iKDW) FOR 1ADDITION <br /> I SECTION 371 6 OF THE FtA LABOR ON, INTEREST, ATTORNEY'S FSES, AND DAMAGES A3 <br /> OvjDeD <br /> I _ C-S7 i7 rwsd •uUeor�scd raPrgscntativeF. hore6Y <br /> iurhorrre ' <br /> tot <br /> nth <br /> Sin Joaquin Carty Well Pe"KAPpticatlon on my behalf. I understand this authOrt2ation l% valid for <br /> ono 191 y .ear and Is I(mited to tho work piece detod On the troll page of thlP application, <br /> INDt'.,d wrroq ° tV ( ti�� I - va-r1 I <br />