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06/22/2PCI 17: 35 7073745677 WOODW;ARD DFILLIN53 CO F-= E 02 <br /> F, S <br /> 16:�0 MODE5rJ ATC PAGE 02 <br /> 06i:%2/2x01 209-�,S , . . <br /> San Joaquin County Environmental Services,Unit IV W411 permit Application Supplement <br /> JOB ADDRESS:••.,, )IkA,1,�'1rA 4UkIMIC PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION 4&—D) <br /> 1 heraby af`irm that I am 1+censens under <br /> re e rmys license 13 in fi Ielr 9 (c and effect$. with Section 7000)at OlvisiCn <br /> 3 of the Susiness and Profess �] <br /> jf Expiration Lyate: — <br /> License#: I <br /> Date:_ 7- Contractor: <br /> Title: <br /> ISignature: <br /> 1 printed narrTot <br /> 1 WORKERS' cOMPENSATION DECLARATION <br /> �I under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I Hereby after <br /> I have and will maintain a certificate of consent to self-insure for workers' comps e�m�S issuEm ed. for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this p I <br /> of <br /> he <br /> I have and will maintain <br /> the rk k for whpensanon ich this permit snissubd required my workers'ornPensa ontinsu anoce ode, } <br /> } for the performs <br /> l <br /> carrier and policy numbers are: _ <br /> 5.'v�, r � Policy Number: <br /> 1 Carrier: <br /> 1 cer:ity that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as be Coo �workers'subject o omp nsation provisions ion laws of Qelifornia, end of Section 3700 of the Laborrcode, I shell <br /> should becomesubject <br /> fcrthwith comply with those provisions. <br /> Date' Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANo CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS i <br /> PROVIDED N ADC I SECTION H BCOFST OF <br /> LABOR CODE. <br /> -87 <br /> INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> I <br /> ✓ � <br /> 7 (G•S7 licensed authorized representative),hereby <br /> 1 <br /> to sign this San Joaquin County Weil perrrdt Application on my behalf, I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> 5-17.2000 t Ali -- -�- <br />