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v3�uL/Lvv3 i'1Jtr Lv:4rC J''A.L �uvr <br /> r11h15u1i?� 'Er-A-IR <br /> San Joaquin County Environmental Health Departmvnt unit IV WAI Porn-pit Appi{cation Supplement <br /> JOB ADDRESS:-Z2 5 41"/--•• %`Air" 9PERMIT SR#: , .._rte_ <br /> LICQENSED CONTRACTORS DECLARATION (L,,,.CLI) <br /> 1 hereby Orm that i am licensed under the provisions of Chapter 9(commencing with&-ctlon 7000)of Division <br /> 3 of the ausiness and Nto-essigns Coria end my license is in full ford and ct_ <br /> License If~:_ ! xp tion Ualta' LJ� <br /> DFft Conte Wr Vu <br /> Printed nurtae: + ' <br /> WORKIGRW CO PENSATW DECLARATION <br /> 1 hereby affinn vndm penalty of perjury one of the tcliowlrg dc*clarations: (CHI=CK ONE) <br /> I <br /> I hexa ltnd wUl nraintain#cortificato orf consent to self insure iorworkers'compensation,as provided for <br /> t>y Sedan 3700 of the labor Code,for the perfom'ancn of the work for which this parMit is Issued <br /> I have aljcJ will rrteinta h workers'compar!sation Insurance.ns muired by,Section 3700 0 the tabor Code, I <br /> for"parlommnoo of Ute work for which this permit is Isnued. My workers'compensation insurance <br /> cnirr lin ctk y num <br /> CSRwr:� are: <br /> � Policy Nunrl+er: <br /> f <br /> }certify that in the porformanos of the:work forwtorh this pemtit is issued,I shall not employ any person In <br /> any rrmner eo as to becOrita 3u6J9Gt to the workers'competts*Uon laws of California,and agree that if i <br /> should become sutct to the wprfcera'cAntpangsr n prev�i0ne of Sadlon 3760 of the Labor Cade,(shall <br /> forthwiw Comply Wb those provisions. <br /> Date: giQnrrturt: <br /> Preretart NAR1o: <br /> •tNARwn:FAILURC To saCURE WORKERS'09WERSATION COVERAGE Ig I,INLAY1tFUL, D SHALL SURJECs <br /> AN EMPLOYER TO CRINKRIAL POIALTIM AND CIVIL FINES IJP TO ONE HUNDRED THOUSAND DOLLARS <br /> I <br /> (SJO0,006.),IN A001"11ON TO THE CosT OF COMM-NSATION,INTEREST,A1-IORNI:Y'S FOES,ANO 17AIYIAOEC As <br /> f PROVI0Fo FOR IN$GCTION 3706 OF THE 1 0011 CW- <br /> THORIxA77C FOR 0 THAN 0-67 SIGNING PERMIT APPLICATION <br /> i <br /> .(9lgpRtur4 00-57 ltcarrsad authohted rop,IcsantntiVal, <br /> now <br /> nar4by 9ltlihorrn(print name) . — --- � ------�– <br /> to sign this San Joaquin corinty Yorell Pannit Appiluation ore my bahalfr t understand thlo aulhariratlon is v0d for <br /> u+r!(i)yew ot%d IE Iimlad to the work plan dotud an the front(rage of 11333 2pp3k4Kt10n. <br /> U r' :I ll i j-:•'r .;r 'H I r17 :; � f f.� .1 {:{'.• <br />