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'A 1.11@IMM) <br />OtiL� <br />San Joaquin County Envifo"Merrtel Y,earm Dopirtment, Unit ly wea Parm4 Applic <br />atio <br />n.4upprement <br />JOB ADDRM: '��� ��7 E Ctt�Ti (� � �f p�IYAY $W. v`C <br />LICENSED CONTRACTORS DECLARATIONL( CD) <br />L horeby affirm UVt 1 Orn KCWMW und""provfsiOnc of ChWer p (Cw=Qmktg with SDCWn 10W) of D1vie1on <br />3 of thv Business *W PraRtsslom Cafe and my k mmss is infill fmO "►0 etied <br />Exp-".afion Date: <br />Djde:Z , I D CorRractor <br />CAMPENSATION DECLARATION <br />I hereby ofFirin under mt4ty of prx;ury CAQ of tha fol" dgclmaww (CHECK ONE) <br />I have and vwn MwintAn a VMIX(*a of consent to satfdnsum for workers Q=PQr=5m ra provided for <br />by 5ec"m 3700 of Sts L*Qr Code, for the perrformeMC* 4f TW work for Wh{ch IN'S txet 1 i~' in5ued. <br />t have and w MI rim3inW wVwm' erlsaIlon tnsurzncc, err requkwl by Seals^ 3700 of the I-nnur Gods. <br />fur Me perform-nca of the worfl %or which re, permit Is tssuad. My workeW comperlY dim mcut nm <br />cmiw end policy nutibam are: <br />Caf ier. 1�'� �][ PolicyNumbor <br />I esrtify that lm the peffomwro of tha work for which tf,is pem A is "ved, I shall not enVoy my perw in <br />arty manner SO as to bemrne subgo m the workrrrd mrgpousaton laws of Cai1(OM& end agree that Lr I <br />should become subjed to :he workme aompensabuo pruvsi= of Section 37'04 of the► labor %,off0. I f&.W <br />,o* wcah comply with those provi orz. <br />EXpIratfon Dabs; igfrfrturo: ..--. — <br />pftnted <br />WA1R1 YNG: VAiL AC TO SWUM MRKEW COIIIPENATIpN C Ir is UNLAW 1,11, A111) SHALT. $tJR*-CT <br />AN EMMOYM To CROANAL pEwu_71ES Amo cnm nws tip -ro ONE HUMAGD THOU OO WL1 ARS <br />($1W,000- , IN AODM39 TO 1'00 COW OF fa0wWeM,•%AT"k fflfrtftMT. A710f0t El"s FEES, hitt) OALMAM AS <br />I PROVIDED FOR IN SECTION. T?w cup THE IARM COO& <br />AUTHORl7AnoN POR OTHER TH" C-57 SFGMNG PERMIT APPUCAZ10M <br />Ijsianatu.a o[C 67 QdM1R4d acrtbo►ized cepr..Mltative)r <br />k i5 � (� <br />hsrrhy auflwr#e !per rtofnat �..�„�_. - <br />to sir this San Jo quin County well Permit Application on my bL. I urw.rtt fa this au0Kwh tlon Is valid for <br />one p) yawn meed it Itmfi►d to Vw wrk pear calm on no fmrd ptiq+ of heirs Wficad6& <br />