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{ <br /> FROM : Ground Zero Analysis PHONE NO. : 209 838 9ee3 •N" Nov. 21 2000 11:33AM P2 <br /> cells, ay, ul•n.Jy JI'lLdlily at ivbl,LI;W, l:lu. , yz:s ala uaue, vuv z -uu l l .u;.r, rave ire <br /> a <br /> Bain Joaquin County Environmental Health servie",Unit IV Wall Permit Application supp)*malrlt <br /> JOB ADDRESS. PERMIT SRO. -07 <br /> LICENSED CONTRACTORS DECLARATION ( } <br /> I hereby affirm that I sm licernsed under the provisions of Chaptrar D(commencing with Soction 7000)of Division <br /> of than Sualnems;t and Profhssions Cede and my license Is in full force and affsat. { <br /> Lio2nae t (a5LR 4n-7 Expiration Date: 1 b 132 L b:g= <br /> r <br /> Date: t't tr Contractor: CmrL�±A llrw�� <br /> Signature• Title: / 7 `.. I <br /> Planted narne:. . -- <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm,ander penalty of perjury one of till fallowing declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a eertifit ttQ of consent to sell•ihoure for workers'compensation,as provided for by <br /> Section 3700 of the Ls"r Gods,for the performance of the,work for which this ptrrttit is issued, <br /> ,,,,wve and will maintain workers'Cornpens3%�on insurance.as required by gectidn 3.''00 of the Labor Code, <br /> for tha performance of the work for which this permit is issued. My workeW aompons ation insurenea <br /> carrier and galloy numborsl 11W <br /> Carrier: ,T Policy Number <br /> ✓1 oertifj!that in the pserformanca of the work far Which this permit is i9sued; I shall not employ any persons in <br /> any Mannar 6o as to become subject to the workers'tmmpensatlon laws of 0811fornia,and agree that 41 <br /> t frould become subject to the workers'comPenSStFon provisions of Ge4tlon 3700 of the Labor Code, !shad <br /> forthwith comply With thou prOW610115. <br /> Data: Signature: .._ <br /> Prirltsd Nalrna: _............_. <br /> WARNING:FAILWW To 65CURE WgIRKILIW COMPENSATION COVERAGE IS UNLAWFUL.,AND SHALL,SUBJECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES ANI?CML FINES UP TO ONK HUNDRED THOUSAND DOLLARS <br /> 0466,eti0.),IN ADDITION TO THE 0057 OF COMPRNSIATION,INTEREST,ATTORNEY'S FEES,AND DAMACFS AS <br /> I <br /> I IR&fDeO FOR IN$20911ON 97 F T40 LASOR CODE. <br /> 11 r <br /> { I, �✓ >;C.57 Naarsase s►pthnrized repro3otitativey,hereby <br /> I e�ehorls� J"l3Lc.n S�es <br /> W sign this Son Joaquin County W611 PesrMit Applloatldn on my bahatf. 1 understand this authorization is vatid for <br /> one III yene and iy tlrsrtfed to the work plan GsWo an the front gaga pf this application. _ <br /> sed 144W'92 000Z L 1 'A6h1 2888 8£S Goa *ON 9NC H4 s!SA T sub oaaz raunadg WCWJ <br />