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.•a:+ .. . vv a,.. ..,p. aie'nr wuvUwr�ra 1- IU I-� /4-Ob II P <br /> Sart Joaquin CounrEy EavirnnraCntai Health Srnrlcas.t7t+iR N Wall Permit AppliCBtlo�Supp{ement <br /> PERMIT SR#_ <br /> - <br /> 90B ADDRESS' — <br /> it <br /> -fCENSED Cp�'tEtACTORS DECLARATION' (LCO <br /> I hereby aftlrm that i am Itaensed under Mee Provisions of Chaptlr 9 tca"T"Inririg with Section 7000)Of Division <br /> 3 of tht 6tuine s OW Prof r s Code and roy license is in full force and effect. <br /> j O©"7 q- �- ExplIation Dabs.__? t 03 <br /> pater �.� `7 I�� —r�arttracta: �+ <br /> r Title- <br /> Signature: <br /> Printed name: <br /> WOMMS-COMPENSATION DMLARATIf?N <br /> I hereby of kin under penalty of perjury one of the Mowing de"latiOns. (CWECIc ALL TMT APPLY) <br /> I trove and wall m3gttdb a Gender ate of by sett tnsea a for war,wt O his permit <br /> is ss provided for by <br /> Section 3700 of the Labor Code.for the performance of the work for wt►idt this permit"s Lsshe L <br /> I have ars!wit rnaittialitVwkers'�6W InsrMnce'as required try Section 3700 Of the 1a4or Code. <br /> for Me perfosmance of the wofk for which this Permit is Issued. My workers compensation insurance <br /> earjw avid pole►numbers are: <br /> .. �'.�,�•�+,�. �� t>oRey Number: <br /> Carrier: I^� <br /> of the work for whien this permit is Issued.I Shall riot emptor any Pio <br /> 1 cnstltY that In the -subject to Ike workers corripensatfon laws of CaGrornia.and agn�That if t <br /> any manner 60 as to liecarte: , pansadion provtswrrs of Section 3700 of the Labor Cade,1 shall <br /> Should become%Mjad to the wwksts <br /> fwt with com*YAM 00se ptovisiorrs• <br /> L��sl�n•®' <br /> Date- 1 <br /> SMM <br /> P�iir►tgd Name' <br /> iMCRKERS' NSAII0N COVERAGE IS UNLAwrUL,AND S}IDL,SUBJE�- <br /> WAF a mo:PAWFI1=70 XAI.PE THOUSAND DOLLARS <br /> Ant IMPLMIMPI To CatltUiNAI.Pout-mss A�°crud.tis t�M M tua+ta�a <br /> MORA=).IN AD0rrl( t To INS COST OF CORPERSATION,zINTEREST.AYTt?FtltEY'S�S.AtVQ DAIRI►GES As <br /> PROMM Folt IN SECIttM 3706 OF THE LA9*R t VIL <br /> 1 <br /> rcettsa,e aaAhd nom►mwmudw�hereby <br /> a 6:14 ;4 � <br /> nmt � t ooriz �,. (I}u r 0rte. <br /> to sign this San-%"a r+cowftvftu ParrrA Appdcatiou on my behalf t undgmtand this authorization is vaT�d for <br /> one(1)]loo'and is Hearted to itis wM%Plan 69"4 an the 6orrt Patio of this appoca"GeL <br /> 5-17-20t1Q/� <br /> Z'd BOIL-988-QES SMIN33MISM3 HHS daa:ar EO LO Kee <br />