Laserfiche WebLink
MAY-07-2003 14:46 URS CORPORATION 15108743268 P.09i13 <br /> MAY-•05-2003 1625? URS CORPORATION 510 974 3266 P.02i02 <br /> San Jaaatvin County Enviranrnantat} 6alth Doparlment Unit fV Weil Permit ipplimion supp atr+cnt <br /> JOB ADD R�.iS;3 r��,v D PERMIT SRS: <br /> LICENSED CONTRACTORS (,DECLARATION (LZ) <br /> I hereby affirm 1*at i am 5ren3cd under the pmvislons of Ghapiur 9(:omMenc!ng With SwG cn'(Uoo)of Diviel0rl <br /> 3 of thr:Bueineml to iabefes <br /> d Pro :ione Code pnd my li:tnse is in full force 4hd effect <br /> Lu;pnee p; <br /> 2. 55'56 Expiration Date; o <br /> Q%�^� �Cerivvinr �` d -/ <br /> 6ignaar.: � _T✓ _ TnI.: �,l Li✓1G� I7Qq _ <br /> Printe4 narne:,�� r-^�ef✓lC <br /> WORKERS' COMp1rNSAT'ION DECLARATION <br /> cb affirm unCar ponattyof porjury oris of the lollewlnq dcxlar9tion5: (CHECK ONE) <br /> I hitt y <br /> _1-h3v9 and will rnaa'it�in a certlfiet3te o`Conean,to sotf•Instire far wo[kers'Gamporaa"on,ac pcati'idaa rot <br /> pie SAetion 3700 of the Labor 0000.for tree psrformznee of�e work for whioh MIS PoRTt t is ISSUed. <br /> 1 have ant w1l,m,intzln works W wI-1,penaalion Ir13,lr�neo.3s raaulRtO�, SsPCIi„,4700 of the.Labor Cade. <br /> I;crthe Derlorm2rce of theewaric furwhieh thi9 pormit it lawad. roy wurken.'eompen3fj n inruT3nC0 <br /> carrlor and policy members ere: <br /> Garriar policy mombor: <br /> C4rtHY <br /> t,zit In The performance of the yolk fpr winch i iia?ermit is iaou6d,1 eholl net ompioy any person in <br /> any rn�tnr a 90 as I'D t:&Wma subject to the wurkers'compEr3otlan iawa at C91lrorn:a,d d parr_n fust i4 1 <br /> shotMjlltseroomc suOJaci to ilio workers'comp'tn:mrtian araviclons t7f ggpmr d7DfJ of the Labor Gott,I cn�l1 <br /> "Kwltn eornpiy wish those pravi3ion3. <br /> pate •.-. Stgnatuco: <br /> Printad Nance: <br /> vYr <br /> AND ZKA.1. <br /> nN EMIP OYER TO CRIMINAL PJi ALTteSAAND G VIAL FFIK1d9 tip TO�Njjv, ON �uNDRE�H=3A O DO LAR6U�eCr <br /> p <br /> 9ROV1FOR 0DED ADDITION <br /> ITION TO Oft HI"COST OF <br /> TML tvaXMp GGATION,INTLREST,ATTORNEY'S PLiEG► AND D"ALCrq As <br /> AUTIdOR 7-ATIdN FOR O HER THAN G-67 SIGNING PERMIT APPLICATION <br /> —(c:gnstv►4 etGrxr lionised btrdtortt4 roPtypantaLlvsa), <br /> 1, <br /> hanehy authwiLc(Pura namo} — <br /> r;pn tlua Liu+-iooqutn t:ouny(Wrli PsrmitApplication on my t;nhblf, I ynderstand th 4 a►+tt+anz�ltan i�rrU4 tar <br /> ar a(1)ynxand is limltcotn ttw wuvk plan doWd on tno flour pipp.*of ehls apolfo"wL , <br /> --- <br /> fib 3"dd 21QD�d FtLli�! EEPE69VGar 6a:vT swizlrr8fari2 <br /> TOTAL P.02 <br />