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<br />09/05/2002 08:56 2094671118
<br />SEP- 3-02 WED 525 Ali D, E.
<br />8F.1/26i,AR2 1S:27 2094671118
<br />San Joaquin County Environmental Health Departnne t Uni
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<br />Lice
<br />Date
<br />Sign
<br />Print
<br />JOEADDRIale j 'Ailti
<br />3 (YZ /..awassisivi Animas,
<br />
<br />Conttt ctor. 0
<br />jape:
<br />*.lirigaric diffiliv4owy
<br />
<br />RIPORIENiaits a:... 1(
<br />W CORM' sP6WkW§MLOMOVOINIOION
<br />1 hOtOby affirm
<br />under periaifY orPerlurY unolgrNa-rviC&Arlg flitf06040,44.CttElig&LAt-A
<br />LAITTHAAPTPALYPIPLY)
<br />I here y affirm under penalty of periu v one_of_th irai
<br />I ave and will mai tam n Ltificai* ,e-of roft.n@shoriatin;vPotre4(11:reocivifderdbyfor by
<br />S Is1;i,v,1 7 0.5tt'llifici4atfotif#716-felganflatei/COVVIMM°16tfi'641frairk or which permit is issued.
<br />RiT@figtwatjeavtheiostwicwolinglep rlati5Atfia.rtql-tiaditly SeiNtifras* OticgT8bor Co
<br />Section 3700 oflhe Labor Code,
<br />416613V°4"4:1fikac611114"1""5111 issued.InTelu6 by
<br />rier aadr2pliqo porqbasitaltaW afc:
<br />e
<br />My workers' compensation insurance
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<br />JOB ADDR, S ,
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<br />T" by affirm that I 0,1-19,0gElun9e9fslihe provisions of
<br />CLARAT1ON LC
<br />f Chapter 9 (commencingswiNairtkkorbFtgila D
<br />E
<br />:..1. ,V.
<br />he Business and Professions Code_Jancl pyy 4frigrecift tnett91(tOrtait recNifretti. e 1-
<br />s 764 der VA Pr 8 I hreby affifrl-iint 1 irp.,5c4 rL.- l'incod ) d my titfinse is In TvIlforcs ar14
<br />le.. : i„in.A..,.• - :n4 FlYisccrli . an Expiration Date: '
<br />txplfstion Date:
<br />PrIntKI name%
<br />9
<br />*
<br />policy Number:
<br /> olicy Number:
<br />k for which this Permil
<br />AGE STOCKTON
<br />FAX NO, 916 852 9558
<br />AGE ST00{11,4
<br />' IIIELFAINffis•
<br />3--
<br />I e
<br />ation Supplement
<br />grlion in
<br />•
<br />er:
<br />Date:
<br />Printed Name:
<br />WARNIN
<br />AN EMP
<br />(S100,00
<br />PROVID
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<br />oCT
<br />r an
<br />
<br />is limited to the work plan dated on the front page of this application. •
<br />
<br />1-25-02 / MI
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<br />PAGE ??
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<br />ANklkfailW Ere -st00
<br />qyittonownakiicti
<br />luvADEu-nOictiqkii
<br />D FOR IN S T ON 370
<br />6-k6 W,! Al: 6: I ' 6 • •
<br />OF
<br />1, AT Niff Agi
<br />hereby a
<br />to sign th
<br />one (1) ye
<br />daa 1 •
<br />.1 • riza ion is valid for
<br />DI
<br />I c rtify_titrINYfliMitiAPen-Nagcl 904 tin* taisthErhAllIgrtWARt'
<br />an ma niafd 444tirt rittlizotopMgqViifiMalion laws of California, and agree that if I rrmwrtnr#,Ipia yi1/2 e sht id bg6c1rogio , VooKoplffulsiztsmpensation provisions of Section 3700 of the Labor Code, I sha
<br />fort with f88 twit those provisions.
<br />S nt Dale: ------r—ignaltUrae:u":
<br />i5 UNL
<br />WARNING: FAILURE To SECURE WORKERS' COMPE/45ATIOg
<br />cOVERAGE AWFUL, AND SHALL SUBJECT Printed Name:
<br />5 OD civiL FINES UP TO ON e HUNOFIDItithfSoc-14U A RS
<br />E.P.8 AND DAMAGES AS
<br />tha wo! ritornia, snd Bgree that 01
<br />/601t6RAVInlibtOP019,0,6A0-1
<br />cittgptiwurtmocritgkErS I9AIfUL, AND SHALL SUBJEC
<br />GititiftfitSCUP TO ONE HUNDRED THOUSAND DOLLARS
<br />MPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS
<br />Rer (C-57 cs rii holder), hercoy
<br />(consvItirig). in sign this San
<br />icensed authosifed reekoweritative),
<br />thyji% fftailippOi rr,y@i.s.:. tui*rsLtnel this siuthorlzation Is vaii or one.‘i
<br />s- PAStkittli ettiiintyrWirPtiMitriRali fcr:trAritigrl m ITeah:PI Tal: •
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