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95/17/2612 68:32 91633904, 4 ATC ASSOCIATES INC PAGE 07/10 <br /> VMJ-PMW AM <br /> EM 2901 C?MMo <br /> I <br /> San Joaquin County 9t1v1r0rnnental health Departawd <br /> i F ,&RG►Rimo PI;1'NIT APPLICAVON SUPPLEMOR NAL <br /> 1 <br /> J013 ADDRESS' 'T �LVdk A ORMIT SR 0 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> with Section 7000)of ' <br /> I l hereby affirm I am ifoensed under the provislons of Chapter A(cAmrr r'rg ; . <br /> Division 3 of the Buskress and PrOfesslarls Cede slid my Ilcertse IS In foil W and effect. I <br /> Licensencp Date: <br /> j Dere: !. <br /> Print[dame, rr r <br /> WORKINRV CVMpENsA'i'#O[d DECLARATION <br /> I hereby affirm under Penalty of perjury one of the followIM deoleratbw(check oris) <br /> I have and wfll inaintain a certificate of oomsent tb soffansure far warlcers`oarnpensatlon,'as k <br /> pnbvlded fer by Sectlon 37D0 of the Labor Code fvrthe perfarmance ofthe work for which this <br /> I I <br /> permit Is issued. <br /> i set hzsuranc as olmd b Section 3700 of the i <br /> 1 nave and wllf rnalntatn warker:� carnpan. Ion .Fs4 Y <br /> ' Labor Code,for the performance of the work forvuhich this psrrnit Is issued. My workers' <br /> i <br /> compensallon fwttrence osidar and polloy numbers are. <br /> � <br /> Number. <br /> i�., tuttrn , <br /> carder.- �, �- - policy <br /> I c eAffy that In the perfarr mos,of the work for Which this pom*Is lesued.I shah not emplay arty <br /> of Cal#fornl and <br /> l carn nstdtlorr law a, <br /> person ts}er,y mar,rrer:;a as to beonrne subJeot to the workers' pe <br /> i free that If I should become submit to workers aoMpmwailon provialons of Section 3700 of the <br /> Lepnr Code 1 shell tprthwith comply with those pra*lone. <br /> i~xp.pate:, f �- _ __ Sl r#atUrn <br /> Print Name: lr✓ ll <br /> I <br /> • VFAI�VINL4�fArl.utttra S2CtlCtE wottrreR6'CGINpEIVSAT1pN aaysRAot ES t3NLAWt:liL,ANn SHALL 8IJa1tECY AH�t.OYER TD <br /> MMINALPERALT120 AND OWL FINER tip TO$100,000,IN AODM011 TO T14E COST OF bOMPENSATIgt3;$tTI 03T, <br /> ATFORNEY*3 Pge%AM D MAOSS AS PHOWOWFOR IN BECTIM TMOF THR LABOR 004E. j <br /> All N FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> f, {slanatursofC-57-iloinsed authortzsd mpresenUdIvs), <br /> herft tutfrorlaa;print nsmp) 4 <br /> stga this San Joaquin Gountyll a6 s Borltta P©rntit AppDoation on my behalf. I uneteretand this auth'orixatlon <br /> fs valid for one year and 18 limited to the work plan dated on tI front page of thfs appltcatforf. ' <br /> ` .....................r44g�em,9�rsw14..... ...._.. . .... ...... ......f, .. "_ rvbatPnorary 1 <br /> i <br /> • a i <br />