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i <br /> 05/17/2012 06:32 916339044844 ATC .ASSOCIATES INC PAGE 02/10 <br /> � W6L4 PPffd1T AFS <br /> E'�b 2901 d1LiEVlO <br /> I <br /> ;ban,loAquln County t nv1mnmehtal Health DOPIMMOnd <br /> i WM- &$ORjNO P SRMIT APPLICATION SUPPLEMENTAL } <br /> JOB ADDRESS.- RMIT SRO <br /> LICENSED CONTRACTORS DECLARATION <br /> i <br /> I hereby affirm that I am licensed under the pmavWOTIS of Chaptas 9(cptr Menckig with Section 7000)of <br /> Division 3 of ihs l3uslnsss and Professions Code and my license Is In full fo snd effect. <br /> Ct�1S Irxp two: <br /> Date / r ContracEul: .l L' I .rte i <br /> Signature- L. Title: , ` ' 2;1 7a -- <br /> i <br /> Pdnt Name' I C- <br /> � � I <br /> WORKERS'COMPENSATION DECLARATION. <br /> I hereby affirm under penalty of pet)ury one Of the following declarations:(check one) 1 <br /> - I have and will maintain a certificate of Consent W$09-Inure f0f-"rRM'aornpensatlart,SIS <br /> proylcW for by Section 3700 of the Labor Code,for the performance of the work for which this <br /> permit Is Issuad. <br /> _1 have and will maintain wnrkerc'comp"patlotr insurame,as,required by Section 3700 of the i <br /> = L&or Code,for the perfot'manoo of the wofk for which this pem*Is Issued. My workers' j <br /> T compenaetlon Insurance oarriorand poflay numbers are; <br /> carder: ftilay Number: <br /> I Certify that In tho performtknoe of ttte work foe Which thlea parfait is fssued,i shall not employ any <br /> pereop In any Manner so as to become subject to the workers'comperisatlon law of Cafffornia,and <br /> t agme that If I should become subject to workers'oompensatlon provistoris of Sactlon$700 of the i <br /> Labor Coda i shah forthwith comply with those provisions, ' <br /> i <br /> Sxp,Dake; EE.d Sfanatur'er <br /> Prlr>t Hams: �r r t <br /> ` WAI NNG:rAl AMTO SECIJ1tL WiPRM984 COMPERSA71014 4;QV&M W UNLAW 0t,AND SMALI.SUBJECT AN EWLOYER TO 1 <br /> CRWHAL PENALTII'.'9 AND CIVIL FINES IJP TO S160,000,IN ADDITION T07HP COW QP 6OMPENSATIOH;IMCEfII:9T, I <br /> A'rIORNErSh'MOAND tFWAGES ASPROIADEOFORIlNSECTION 3=0FTHELABOR CODE. <br /> I <br /> T N FOR OTHER THAN C-57 SIGT41NG IPER101T APPUCATION <br /> 1, (signature of CV.-Ilmnseti authorlmd representative), <br /> hereby authorize(Print"Mae) <br /> sign this San domtuln CtQrRy Well&Boring Permit Apptiomdton on my bohelL l understand tfris mrlAorixation <br /> Is valid for one y$ar and Is IlmW to the work pian dated on ft imnt Pape of this allPffeatiolf ' <br /> ' I <br />