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San Joaquin County Environmental Health Service!k�bVA ell Permit Application Sut?pW-mMt <br />04/27/2084 15:49 2z9-579-2225 <br />J ,ADRS' //S.To cJ. c1r,7- rrlec xi), s-o<rro,-1PERMIT SR#: <br />t� J <br />Po�mi4 A+clica+eon Supplement <br />i JOB ADDRESS: ^"JPE�M3"T SR#: ;II <br />I herby affirm that I am licensed under the provisions of Chapter 9 (commencing with Sect on 7000) of Di+ion <br />3 of t I e Business and LICENSED CONT � ec beg��LA"-"ON (LCO) <br />iIf <br />Licen e #: Expiration Dater me _ r.:�„ +rano of OlVsion <br />I cv <br />herehy 2ffrm that I am c 1c9nsed ander tn8��rm�:si�®n 8 g a�u I �Orca a effect, <br />r� �9 <br />Date: 3 a. the Easiness aM • rufaa <br />i't4era4e) 62 <br />7,o q© 7 Expiration Date: <br />Signa 14 ' le: C - <br />Date: Contractor: <br />Printe name: 6,rvd`T "�-- <br />Signature:r <br />Printed name: ERS' , <br />I here y affirm under penalty of p 4i i o t�r��� i h��' OCfarDa ons CHE' K ALL THt T APPLY) <br />u r,e of th fol!cwing declarations: (cHECK ALL THA APPLY) <br />I h�a "M4YO f NMAWed'A ftRic � o �onsenteto self -insure for workers' compensatio as? v�c�ecibfor�by <br />Section 700 W, y <br />_ ,700 i i t ��4: r°�ee tRic � r rta��f irl''oa+����K r79cf�°fHf gree e <br />Section 3700 of the Lator Code, for the performance of the work for which this p rrni s s' <br />I hve nd will maintain workers' compensatio insurances a , �tRiC7�{mfidiCa+i'►r�f�o e, <br />ror�tf rf a AlC ll t#`f� bYf�' fry fS1 I p et r�jl.H � c &fid.MUyy ers'ar®nppez dlf��f�''§nce <br />r 4 1 e warn or w i <br />carrier at'R€i � r"� A�to��6pr <br />caer poi cy'1c �tS are: I <br />Carr'er: �- <br />e ��� > :he Werk r r•which this permit is issued. 1 shat' not emlcy any person in <br />I c rfi til ff�i ' JwQ��' a Ql t tii 6Miad153"51Pf Cl41W *1@MP,- <br />a s�n to <br />c s as to ecc'+ <br />any mane J' best gr esE8, ?J l o Rt c5�6f d sat�rrp�o atim�fl@dt 19�P � P a a� I <br />should b {p , ,p�ttt� or et !cowpensati n ins of Section 70 of�the -abor Code, I sh11 <br />forthwith co ly th s i ions. <br />Data:Signature: j <br />Date: _ I�drt�a <br />WARNING: FAILURE ToFb#cti;tk. WMI16FRs' CoNiPENSA?lG440VFRAGtE 1S UNiLAWFUL+ AN MALLSUEJECT <br />WARNI,�SN EMPLOYER TO CRIMINAL pENA A—�N COVERAGE IS UNLAWFUL, AND SHALL SUBJEC <br />aa IQG^r IM PENS INTEHESTj ATTORNEY'S FEES, A 0 DAMAGES <br />AN EMP O MT <br />A EA TIE AN CI IL FINES UP TO ONE HUNDRED THOUSAN DOLLARS <br />($100,00.), INA IT b CO C ON INTE 'T 4;; #�fh6 61JiMhCvE* AS <br />PROVIDq,FO <br />I lutharfss14 :Ine� <br />I, oun 1M1�sit Psrrntt A plitatlon ort I r nd.!hf suthar atton is valid for <br />,.wtI P (ey"gRltns�%at?ionze� representative), hereby <br />authoriz ane �1lid 1,004!0 em r L�ln dated on the front page of this appttratian. III <br />to sign tf-4 ""'�� rmi pp kation on my behalf. I understand this autho ization is valid for <br />one (1) year and is limited to the work pian dated on the front page of this application. <br />5-17-2000 1 MI <br />)_. ---- — --- - - - .. <br />2-d STLS6TCSZG uapTen Rueu dCT=bO to LZ add <br />