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3- 11-2011 10:30AM FROM P_ 2 <br /> .•,t 1 1-�kn_,a .it•�:Wn t s�L' ..'..Gr-1 1 Uf'i jHl V !{Hf VJi tl <br /> INV N.� <br /> San JOGWuin.Couift EnVlr0n n R4J health OepartmontUnit IV Well f'arrrllitAppilmdon Suppiamem <br /> PG&E SUMON Sa M rA Gn"r,4040 V*St Lana, <br /> JOB ADDRESS: Stoem n,cA esz04 PERMIT SRIF <br /> i LICENSED CONTRACTORS DECLARATION LCQ <br /> i hereby affirm that f am Itcensed under the provisions of Cnapter A(commencing wan Section now of Division <br /> 3 of the Business and'Pr alingions.Code and my license is in fail farce aril effect. <br /> License Ii; B486e5 Expiration Date: 12131106 -�-----_.- <br /> Date: TIJI Contractor:F,C1-} _i ry;rZ _ i�►�C_,r�' c• f <br /> Tide, <br /> Printed name: r e-*4 <br /> WORKERS'COMPENSATION DECLARATION <br /> i hereby affirm under penalty of perjury one of the following declarMlons: (CHECK ONE) <br /> i nSYe and 00 rnair twin a C9 Wcate of WgSerit to.Self lasumr.for workers'compeneation,as proved for <br /> by Section 3700 as the Labor Code,!for ft p'w mnn=of the,ww%for which this permit is Issued. <br /> r/ I have and will maintain woi*ers'compsnsA*n insurance,aG m4vired by Section 3700 of t;i®i.abor Gole, <br /> for the pprformancs of the work for which hila permit is lasueq, My workers'cmrperlsatton-insurance <br /> r <br /> carrier and policy numbers are: <br /> r - J <br /> u►""�Policy Number. <br /> Carrier; `S C <br /> r <br /> certify that In the(xFforma.nce of tete work for which,this permit is issued,I shall not employ stry person In <br /> ;Rrry rnanner so as to.becoMe tL bjW tp'tita.vmr kws'comp�n".0o 1°lews of Calitbmie,and some that if I <br /> shmAd become autleetto the workers'compensatiamprovisiorts of Section 370D of the Labor Code,f shall <br /> Forthvath comply with those.provisiona, <br /> Expiration DOW: G 3/-O Sluqlatare. / <br /> f <br /> Printed Mame: is e-- <br /> WARMING:FA ALURIE TO 615WURA•WORKERS'C=PQ"TIQN.COIRERAGE IS UNLAWFULW AND SMALL SUBJECT <br /> 3� AN:EMPLQricR TO'CRI1fFtINAL,PENALTISS AND CPAL LINEA up TDONI:`"U!IDRE9T►O0&AND DOLLARS <br /> I <br /> WWW-).I N•A6)tJ1TlON TO'THE COST OF COWENSATION,INTEREST,ATTOW4&Y'S FEES,AND-DAMAI 4S <br /> iPROVIOSID FOR IN S15CTION$704 OF Ti$E LABOR COPE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGMXG PERMIT APPLICATION <br /> i <br /> 1.-- i_���1it:' f�00��tr � _ _, lafeRsp,rro ofc��;{oensad.aueborlxsa+rprsssnlativa.), <br /> hereby authortze(print <br /> to sign this,San J"quin County Wail PermitAppilantlon on my behalf. 1 urrders od this suMoriatlon is wfid for <br /> one(1)year and is Iknited to the work plap dated on.tete front page tuf this app.1kadon. <br /> i <br /> CiFrD�9-DZ-0ut <br /> 3l90.'z402 <br />