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Ji?• Ly. !!iG: 4: lyrm RQvance¢ uectnvironmentai No. 1904 P. 1 <br /> %MOO r..� <br /> San Joaquin County F_nvironmelftW Health Department Unit IV Web PerlrtitApplteation Supplement <br /> I hereby affirm that I am bcM04d and r the pr+iMsions of Chapter 9(commencing with Section 70D0)of!]wwan <br /> 3 of the Business and Professions Code and my license is in U1 torte and effect <br /> License �0- 57,2— (' 7— Bq*ation Date: d�!O LLD LO <br /> Date,-91 Contmdor: LA SA tL&2A. <br /> Signature: Title• <br /> ftnt€ed came: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affutn under penally of perjury one of the fbikm N declarations_ (CHECK ONE) <br /> I have and rel maintain a certiff ate of consent to salt-Insum forty *ere campeasatinn,as provided for <br /> by Section 3700 of to Labor Code,for the perfonnartce of the work for which this permit is Issued. <br /> have and will maintain workers'compensation insurance,a3 reWsrod by Section 3700 of the Labor Cade. <br /> for the performance of lite worts for which lits permit is issued. My workers'aompensakri inswance <br /> carrier and policy numbers are <br /> Carriiw. SEA I69_A C;;a(+a- Policy Nuanber.. e>tL� �ZLo� <br /> I cerUry that in the performance of the work for which this pesrnit is issued,t shall not employ any person in <br /> any manner so as to became subject to the Yawkers'compensation laws or Calitomia.and agree tial if t <br /> should become subject to the workers'compensatinn provisions cf Section 3700 of the Labor Corse.I shag <br /> kw#w h comply vd(h those provisions. <br /> Fxpirafion Date: t 610 Signnat uw. <br /> Printed Name: <br /> WARtiWG:FAILt1RE TO 3ECURE WORKERS'C OPENSATION RAGE M tIN1.AWFUI.,AND SHALL SUBJE=CT <br /> AN EMPLOYER TO CRIA NAL PENALnES AND CIVIL FINES UP To ONE HUNDRED TWUSAND DOLLARS <br /> j$100.0t10.),ON AUDITION TO THE COST OF COMPILATION,INTEREST,ATTORNEY'S FEES,AND DAMIA40ES AS <br /> PROVIDW FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHOPMATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 4 signatzu.=4-1 Gcassod auumetred reponeabtive), <br /> hereby authorize Odnt nariK Q' rw-X4y-11AW1'" Cr. <br /> to sign rfiis San Joaquin County Well Pent Appiication on lacy behatL 1 understand oris authortmeon is waled for <br /> one It)yew and is lM PAd to the work plan doted on the front page of this spplicatMn. <br /> 3-2"21 M1 <br /> EFtD 24.07rOD1 <br /> 6mm <br />