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a P.2 2 <br /> DEC 1y '1�t� 1� �3 b1ES7 Cry-E1yu.=itiEGi=-Sin- 52�r.i�? {r� j <br /> San Joaauirt County Envlronrnontal Health Services, Unit IV WWII Permit Appiicatlon 9upplomant <br /> JOB ADDRESS:- PERMIT S <br /> C/w4 /3/v <br /> Ll RS DECLARATION (LCD) ' <br /> I he, affirm that I ern licensed ti.-ider the prov,ssonc of Cl,aptar 9 (comrmencing wl:n St;cbon 70DO)of Division <br /> 3 of the Business and Pro'esstons Code and my I:cerse Is in full force and affect, <br /> �icpnse +f: Expiration D,ale: <br /> ' Date: Cantracter: V� l� ��.'y11;Igor <br /> !c I <br /> Signature. Title: <br /> IN <br /> WORKERS' COMPENSATION DECLARATION <br /> I ',,sreby affirm under penalty of per;ury ens of t'ne followir.g de--Ia*Or-s; (CHECK ALL THATAPPLY) <br /> i _.I have ;end will ma!rtaln a cerl,flcate' of corssnl to se;f•5nsurt: far crkers' cornper,sauon, as prav;ded for by <br /> Section 3700 of the Labor Cods, `or th,e per`ormence of the wnrr' or which th!s permit is lssusC. <br /> 1't:eve enc wN r-minte'.n workers' comper oatlun Inslrence, as req,:ired by Sectlen 3700 of the Leber Code,; <br /> for the Performance of the work for which this permit Is ts9ved. My workorb' compensatlort ir♦B�Jrance <br /> zgrrler and policy numbers are. <br /> Cgrrter; PollcyNvnlbar: ,_,J[, � - - <br /> I certify that in the performance of the work for which thla permit is issued, I shall not employ any person In <br /> ��any manner so 0$ -.111111",011)" subject to the workers'corn pen safiCr itsn•s of Colirornle, and agree ihat If 1 <br /> should become subleol to the workers'corrw$etsan prov!slons of Sa.:la-t $7D0 of ing Labor Gale, I shall <br /> forthwlth comply with those provls!ons. <br /> Date._! hel�r3r� Slenaturna � _ _. <br /> Printer! Name <br /> WARNING: FAILURE TO SECURE WORKERS'COMP PEN$AT]ON COVERAOE IS UNLAWFUL,AND SHALL SUB 607' <br /> ± AN EMpj,0YEfk To CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HU h'DREO THOUSAND DOLLAR$ <br /> (SI o0,000,), IN ADDITION To THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN sEo1•o j 370E OF Tit? t..A5OR CODE, <br /> I, <br /> (C•37llcemisd aulhorlrod representative), hereby <br /> authorize <br /> tv sign this San Joaquin CauntYWO11 PermitAppllcatlon on rnybehall, 1 understand this authorlsstion Is valid for <br /> otle(i)year and Is limited to the work plan dated on tho front psge of this appllelticn. <br /> -5.17.20001 MI _ <br /> r� �::._ GC�:,�_ F�x__ Et;r't637L2L �+� •4 i 23C�/�T/0T <br /> 12/19/2000 TUE 12:31 (TT/R1 NO 15711JI 0002 <br />