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• •.•^. . r fSV3 <br /> P. 2 <br /> ,:,Rom around zero V No. 2ZS PZ-2 9683 _ 06 2003 02:29r Pi F'? <br /> Sart Joaquin County?Unvironmomtal Health tlepatb"Gnt 1.111%;UI f Il'iiell P eaftt Application Supplement � <br /> JPSADlRESS:rD1§1 A1rnandwgcd 06y , WIaftgA,CA PERMIT SRS: <br /> LICENSED CONTRACTORS DECLARATION �, C ) <br /> i <br /> 1 hicruby raffia??that I am Olcenwd vnde,the provisivrrs of Chaplet S(cornmenctng with Section 7000)of rNvlsion i <br /> 3 of the ausincss and Protessiorts Code arrd my titan is in full.fvrw acrd effect. � <br /> f <br /> license#' GAU83 � 5 — ------- Evkattpn Date-^01131f04 � <br /> Date: i" L{." _Contractor: I=iwh EnvirDt Mehl l <br /> Title; <br /> { Printest fIERIC: >+ i <br /> I <br /> WORKERS'COMPENSATION DECLARATION <br /> I <br /> I hereby affirm trader penalty of per ury ome of the tvl.lowing declarationq. (CHFCK ALL THAT APPLY) <br /> —1 have and will rnairAsin a oertdicete of consent to self-4i iwrer for workers'compens2rii4n, as prcv4ed for try <br /> !l SaCtion 3100 of the l_ataer Code. b-the pe ormartce of the work for which this permit z issued. <br /> I <br /> ' i have enc wily meintain wcrrkers'compensation insurance, as reau!red by Section 3700 of the tabor Code, <br /> j <br /> for the perf0imance of the work for which ibis permrt is;rssued. My workars'c=pertsat+on insurance <br /> Carrier and policy numbers are: <br /> E <br /> Carrier: �A- <br /> T I certify that in the parfvrmor%o of thv work tar which this permit is issA.49dr 1 shat)neat Pmptcsy;jny person in i <br /> any rnannrer so as to beCrn <br /> .ae subjert to the mrketrs'compensation laws of CaNfomia,and agree that if I 1 <br /> 5hquid become subject to"wbrkem'oompensation pmvrsi4rns of Section 3700 of the Labor Cotler, f shall <br /> j fnrthw4h comolyr with those provisions. <br /> Signature: .�( �' ! "r` `� ._T,_.�._ t <br /> Printed Maim; if.+ 0 <br /> WARNING:FAIT_ RC-7C ROCU tF YS ORKCRW COMPENSATION-COVERAGE IS ONLAWFUL.AND SHALL.SUBJECT I <br /> i AN OPIPLOYdR TO ORIMlNAL VEMA4TIES AND CIVIL FIRM UP TO ONE WUNDRED THOUSAND DOLLAR$ <br /> IN AMITION TO THE COV Ch CCMPFNSATION,INTEREST,AkTTORNrf-5 I"EIES,AND DAMAGt=S AS <br /> i PRO1 r)F-V FOR IN SIEC-tIO N 3709 OF THE LA6OR.000E. G <br /> 1, � r r/r !� ► -y5�= r� (ollpaatur W-57 licensed authorized represehtatlw), i <br /> i <br /> hereby authoriza(print nafn e) Ahn LMna-gL <br /> to 6i5n this San 4*441;in County W61i Permit Applicatfalt on my behalf. l understanb this authorization?is valid for <br /> Cater(1)year a^d is lir"3*d t0the'wvm*plan dated 6n tht"r*p4"of tlhiS apDMCativM <br /> l.�5-02l�illl �� <br />