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• • Booz <br /> 03/21/2003 FR 13:48 FAX <br /> JA1+/1re) l3nit.IV We11 PermitApPftcation Su.Rptement <br /> San Joaquin Con�ty EnvAilronrttentat Health S.erviaet , <br /> pER (� S�#t <br /> JOB ADDRESS:�I� 1t`y-' <br /> LICENSED CONTRACTORS DECLARATION (LC ) <br /> affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 1 hereby license is in full force and effect. <br /> 3 of the Business and Professions rode and my <br /> no / Expiration Date: <br /> 0// <br /> ,7 (�1 <br /> License#: Gf 1 r' I -Inc - <br /> �j�a ontrador. Aj <br /> Date:'T Title: <br /> Signature: <br /> Printed name. TION <br /> WORKERS' C00rIPENSATION DECLARA <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> rovided for by <br /> I have and will maintain a certificate of conse <br /> rformance of the work for which this permit is issued. <br /> nt to serf-insure for workers' compensation,as <br /> section 3700 of the Labor Code,for the pe <br /> 700 of the Labor <br /> I have and will maintain workers' r whit <br /> nsation insurance, as required workers! <br /> ke Section 3nsaton insurance <br /> ode <br /> for the performance of the work for which this permit is issued My worker��cO� _Q� <br /> carrier and policy numbers are: <br /> �� rte, ld Policy Number: <br /> Carter: Pel is issued, 1 shall not employ any person 1n <br /> I certify that ill the Performance of the work for which this P-nsation laws of California,and agree that it <br /> any manner t) as to become subject to the workers' COmPe <br /> should beoorne whh thosep <br /> rovisions,provisions,compensation provisions <br /> of S tion 37017 of the Labor Code- <br /> forthwith omp y n 1 /r• ,��4 <br /> 3 I Signature: <br /> Date: n \�' r ' vt 1 <br /> Printed Name: — <br /> PENALTIES AND CIVIL FINES UP TO ONE HUNDRET'ON COVED THOUSAND DOLLARS <br /> WARNING:FAILURE TO SECURE CST OF CO>aPENSATIAON,NTERESST,ATTORNEY gFFEES AND <br /> AND DAMAGES AS <br /> ANE 000)IN ADDTOIMI N TO THE <br /> ($100, 3706 OF THE t,p,BOR CODE. <br /> PROVIDED FOR IN SECTION <br /> -57 lieensed authorized rcpresantativf), heY2bY <br /> 1. <br /> authorizebehalf. 1 understated this authocizatlon is Valid for <br /> Permit Application on my <br /> to sign this San Joacfuin County Wellfapplication. <br /> ar <br /> oand t0 the,work plan dated on the front pa.0 <br /> ne N)Yeoti''�s ap�— <br /> WOii� Wd99°v7 l B6�l^DPl–D l <br />