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JUL 30 2003 2: 35Pf'! Dn'tLOS EIVVIRONI`tEl`tTRL <br /> 91UUUUUjzC p.2 <br /> Jul 24 03 10c59a GF :NGINEERING 530-89 '108 <br /> i . <br /> $s <br /> n.loaquin Cauhty Emfiranraental health Services,Unit N Weil PltthltAQptieatiot►SupPlsmant <br /> PERMrr <br /> JOB ADDRESS, +� <br /> sR#: <br /> LICENSED CONTRACTORS DECLARATI G.—CM <br /> ci wtlh rection 7400)of Division <br /> I hereby affirm 4+at I am Reensed under the eiclnsa ons of Chapter+ 1l force <br /> +an h9 <br /> 3 cf the Business and'professions Cadt and my land <br /> �ff f <br /> ExpirMonDate- <br /> License S: <br /> Date: �� `d Contractor. 1, ` <br /> title: 4 <br /> Signature= J <br /> Printed nsnrl: - <br /> W DRKfi RT CUMPMATION DECLARAMN <br /> I hereby affirm undo penalty of One Of'he bIgAng d�ration6: {CHECtt:ALL THAT APPLY) <br /> PO)" <br /> I Ce and wM maWgin a wi tteate of consent 10 selMnsure for workers' mpertsatiexi,as provided fa by <br /> Crime <br /> Section 3'700 of the Labor Code.for the Wf0rManee of ttu4 work for whine this Pe;mtt is issued, <br /> I have and wilt ma+htein wWkers',conVensation Insurance,as required by section 3700 of the Labor Code, <br /> plrfprmarica of the work for which this permit s issued. f�ty+corkers'Compensation Insurance <br /> kPrMecarder and policy numbers ail <br /> Cornton:, � � Policy Kurr*ert <br /> not emptay <br /> L Certify that in the periprmante b�t to thefor wa which colmpemat"wn laws of Cat Rt rnia.3n egre a that iitt 1 u+ <br /> any rs+ rwr ao as to become subjec ansolion pravlslvns of Section 3740 of the t atsor Gods.l shah <br /> shoWd became subject to the workers'cramp <br /> forthwith comply with Blase Provisions• <br /> Daae: signature: <br /> p <br /> Printed Name- <br /> 06 IS UW.AWFUL�AND <br /> WARNING:FAt TO GTo SECURE VR3FFXr <br /> N,r, f+EUilI I.TtESRAtaD Cf1rd-FMSP TO Htf1a17REd 7ItOUSA1�DD+LLA Sl1l�JECT <br /> AN EM LOM <br /> ISl ao 000)•IN ADDITION TO THE COVOFCd1AMOATION.M7EREST,ATTOME"MS'AND DAMAGES <br /> AS <br /> PROVMQ FOR t"SECTION 3705 OF THE IA6QR CODE- <br /> d r 1�. ,d -.--1 (e 7 Rcettaad st+ihorisad teP entattr!),hereey <br /> 1, <br /> autererize <br /> to stgn dos San,ieaqutn CeuntyV!!II parrtitltAppltcatlon ea MY h�L&gif. I undenctand this aut>horiratien is valid for <br /> ane(1)yaoraad is tiMa&d to the wont Phil dated 00'ho front page e1 this sppUc;stion. <br /> s,�-2voa f rrl <br />