Laserfiche WebLink
APR 16 2003 10: 52AM HP LFISERJET 3200 P• 3 <br /> 0a/15r:003 11:56 ^^<09-57� J25 t�DESTO ATC <br /> PA3E 03 <br /> i'1 '-08-19®5 10i1pM FF P.5 <br /> Asan Uoagein County Environmental Hes"tlervlcse.Unit IV Wail Permit Application Supplement <br /> I <br /> JOB ADDRESS: I050 54a.k- - PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATION <br /> haraby affirm that I am Ilcensec under me provulbns Of Chaptar 9(commencing with Soc[ion 7000)of DNISKr <br /> 3 of the Business and P,rookssaPu <br /> ns Gode and my nas is in lull fords and eRscL <br /> Licenami•: GS 7 S/+SS761Expiration Dao: /AV ZO Sk <br /> I Date: r rQ•FP 0r: <br /> lmv�: <br /> Pr rate <br /> WORKERS'COMPENSATION DECLARATION <br /> !; I hereby alfvm under penalty of Perjury one of the lalovinp deehraiwns: (CHECK ALL THAT APPLY) <br /> Ah and will maintain a CortIS0a4 of consent 10 pal-insure for workers' compensation, as providoc fcr by <br /> 9sctldn 3700 of the Labor Code,for the parldrmant:e of the wort:for which this peRnit is Issued. <br /> nays Gild will maintain worker'compensation Insurance, as required by Section 3700 Or the Labor Code. <br /> for the parforn4nee of the work for which this permit 4 issued My weAcefe'eAmpentgtion insurance <br /> Cartier and <br /> policy numbers are: <br /> t Carrier. ®s„( Policy NumberC <br /> _I co"mat In the peAermArim of the work for whicA the pgmn la Issued, I sham not larvoy any penor m <br /> any manner so as to become 4ubjW to the workers'compenelaen Taws of California,and agree Ilial If i <br /> should beoortx subject to the workers'compensafion provWc! v of Section 3T00 of the Labor Code,1 shall <br /> bttlwrith/comply with those 9misions. <br /> Delta: (fflO� Signature: .aeWr <br /> Printed Neth: I <br /> WARNWO:FAILURE T039CWRI WORK9R5'COMPENA' N COVlRAGE IS UNLAWPUL.AND SMALL 6UIWECT <br /> AN EMPLIDYER TO CRaWNAL PENALTIES ANO CML FlNEa UP TO ONE HUNDRED THOUSAND DOLLARS j <br /> 13100,000.1,IM ADDITON TO TNfn COST OF COMPEN3ATON, INTEREST,ATTORNEY'S FEES,AHD OAMAOES AS If <br /> PROVIDED POR N SECTION 3704 OF THE LABOR CODE. <br /> _rf�r An e/• (C-37 acsMed mu*a ted r9praMntnUV4 MwAy <br /> e0lhorlaef?rf'3 <br /> %sign mill San dos"m±linty W*li Penne Applleagon on my behalf. I undambird ths suthorizvti + w valikl rot <br /> one 11)year and N llmi nd to the work plan.dot"on the front palls of Otis A PO4 don. <br />