Laserfiche WebLink
SQO Jogquin County Envfra^.mental Health Serff=s, Unit 3V W011 Permit Appf"vla=i�afrnlent, <br />VICE ACDRESS:' PERMIT <br />t <br />j LICENSED CONTRACTORS DECLARATION &.M) i <br />i ter -,t j zF=r that f am 6cersad under IN Xovisfars of (C0r7lme:IC!n9iWkh Sr Uon 7+w) Of Tsivis;or, <br />3 �f'Jie SurlMss and Prefessfons Cade artd try IlCansn is in full f0foe and affect. <br />L,rzr,sa d 2 �f 5-kpiradnrt Cate: <br />Cats: <br />� Slaratt�ra: <br />Printed =rne: <br />WOR1KIERS' COMPENSA7ICNI 0E17;-iARA7Y6FJ- <br />I 1 weby affir, under penzily of perjury One 3r' ire Following dez1arBIians- (CHECK ALL TNIA-' APPLYt <br />J have and rriii rimintatn Qf ocnsant :o sell-inmra for Cahperysw;Vn, AS pravlcled for by <br />Sacicn 37041 of !he L or Coda, for the petfunnarsc$ at fha work fdf vririch this parmit is tssueC. <br />- i "lave and wpl maintain women, cerrtpert_atlan insurancz as requirea� by .31 ,jjon 3 000 of tl:e La <br />fc: m4a uerformanca or ;Ze runs for wrz di ;ttis permit is )ssuad. 1vIY �ror',sar carn¢snsation nsurarca <br />r. Ger and policy numners ara: <br />P I Number: <br />1 .eriify brat in the Perfar.=Ca If Pte war'c for whlc.'i this Permit '3 is:,uetl,.l opal not employ any person in <br />any rnan", 5O as t0beta e sLt',1 i tv utc w0FKerS' 4onpens*U0r1 Ivw= or California, and agrae ftl If t <br />shculd be=a 5ubjec::c 3}e ,rrcrkoy ;,'PEMaflclI prc'Asicns oi' Sac;icn 3700 of the L41ar C -Ode. f =1 <br />forhwirh compiy wltit thea provisoes. <br />La?_: ( 16 0 ).- Signature: <br />Ar!ntcd Nam*; <br />WARNING: FAD -URE TO SECURE WCM13�7ZS' COMPEMSATIOK COVERAGE IS UNLl WF4 L AND SMALL SUE3JZ C <br />AN EhWLDYER TO c9NINAL FENALTIes AND CIVIL MES t.lP TO ONE HUNDRft TMOt)3ANDi DOLLARS <br />;S 700'00*'. 114 ADDITION TR T' -M COST OF WXPZNSAMQX1 IN't'ER.EST, A7TORI`M? 5 FEES, AND DAMAGES A5 <br />PRVADED_ /1FOR�t IN SECTION 3769 OF THE LABOR JrC00 <br />Ile <br />7 jCSans�d arJtPSOYt2ad <br />. t _ reltr+�en#xtivej, tte�y <br />aut3tarize <br />to slgn this San .ioavuid Cotuet}r Waq Perml;}U:patcsilort cp tuy behalf. ! underat�rtd :h� $g't2tariLiUpq � va:td trn <br />one (1) Year and Is GMifxd to ft work plan datod en ft front Cagy of thb app:tcatjcn, <br />5-17.2000 1 MI <br />