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I : 1 G4,�1 P P.0 10 P. <br /> �ery kraiwzi,. pi-j ip_ Ir- - 209 83a ?2 03:ispN P7 <br /> nt <br /> i <br /> San Joaquin County Envif,*nrTmirital Hot:th DepartMent 1.110 IV Weil Pennif Application Supplemarlit <br /> ' JOB ADORESS:. 23023 S. Sant <br /> -- -a Fe Road, BiXtLkank PERMIT SR#: <br /> LICENSED CON CT DECLARATION (!,CD) <br /> I'Tr.-rcoy aF-rm that I am i;censed v;cut :Ire provisicnz cf Ct-iawer S commencing with Section 700r-.)of Division <br /> 3 of the&x-,iness a-,d Pr feSsjcrs 0"e an%j my icense i!;in full forces arid affect. <br /> -7 <br /> Expiration D;AW <br /> conna== <br /> Signature: -Title: <br /> Printed name. <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm under panalr,,of pe(juty onEzkf t-ye fol.ollfing decharators; (CHECK ALL T14AT APPLY) <br /> 1 have and will m2in:zin a certih-caa,&consent tc self-insLire lor warkets'corm,pensabon,as crovtiw or by <br /> Sewn 3700 cat the Labor Code,for ti!e perlvrntarce*`-',Ile wc,;kfor whith tlhi5 permit S SSLed. <br /> 1,6 have and wili mairtsIn workers'c=persaticjr,im;onance,as required by Sect-on 3 70C of the Labor Code <br /> fol the perfor-mance of the work for whtch Liss per-.14 iT,issued. My warkers, insurarl.ce <br /> Carrier and policy r.1 ucnt*rs <br /> Policy Number. <br /> I certify that�n Me performance c*t1te wcrk for wh0c!"this perrnmt;s issuec. I shall not en.;(0y any person in <br /> Orly nionfler"aS to becoMe Sub,;eot'o'he workefri'Coe-ripervkatior laws-of CaYornis,and agree that if I <br /> snould Demme 0. the werKem'compensation provisiors of Sect;on 37GO of the Labor Gide, i shall <br /> forthwith comply with ese provAions <br /> Date. <br /> Printed Name: <br /> wAwaisG;FAILURE TO SECURE WCFtKF.R$l COMPENSATION COVERAGE t,-,ONLAWFUL,AND SHALL SUBJEiL'T <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FIXES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5iW,Dca.%.in AvviTION TO THE COST OF COMPENSATION,MTEREST.AT 7ORNEIrS FjES,AND DAMAGES AS <br /> PRWvj�FOR Ni SIECTION 37as OF rxi LAscp com <br /> 19v =WC-51 fluenemd sutitorked representative). <br /> hefoby auftwlze(taint rtame)_ John Lam a?Graimd-Zoro Alawnis Inc. <br /> to sign this San Joaquin Coonty W011 P*MTtAPPhd*tiOn On mY.bvh*ff, I U*dVrcftnd this authorisation is valid for <br /> one(1)year and is 1kriftl to the work pkn dated on the fm-4 page of tats apoltoafian. <br />