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2-21-199S 6:O8AH FROM P. 3 <br /> i9r3r 1.ai'1.l�r�I i:t:07. 1IJ9-5ry ;5 NiGDESTO ATC <br /> N <br /> $an-1caquin County Envir nmentat Health Servie*t,Lime IV Wet:pUrertiit Asp"cettivn Supplement <br /> JOB ADDRESS: i�. <br /> LICENSED CONTRACTORS DECLARATION ) <br /> }hereby attrnrt mat:am liee9nsed un(Jer the provisions.ofChapter 9(Conuylencing with Sec <br /> 3 of the t3ussnBas triad 1 fe6slorrs Cede and My licence sS Irr full force and effect. tion 70W)of t7ivisiurl <br /> Lfconse : 5 <br /> Date: - I Contractor. <br /> Signature: Y <br /> � Title. <br /> Prfn.t*d name: <br /> WORKERS'COMPEfSATwN 0ECLARATf()N <br /> 1 hereby affirm under penalty of perjury one of LMe f0dusing declwallorrs: (CHECK ALL THAT APPLY) <br /> `. 1 have and Wilk m8lat8in a certificate of consent to est!-insure for workdrs'.cwpenseti0rr,as provided for by <br /> Se vion 3700 of tw Labor Code, for th*pei4ortrtrxrire Of flee work for whin this permit rs issued. <br /> zt hm*O acme wife Maintain warkera'COMP"sgbon insurance.as required JJy SecWn 3700 of the Labor Code, <br /> for the pbeiarrnanm o!•tho work for%wNch thts permit is issued, ray w0*ers'a arnperrsation insurance <br /> r <br /> Carrier and"if"y nums are: <br /> Carrisr -- Policy Ott mb*r• <br /> 1 cOrtify that in the pe rhmrfanae of tete we'rk for which this permit 18 issued, I shaft not smocy any person in <br /> my meaner so as by NfCame subje4t to the workers'compea cation laws of Caflfomla, and agree that 91 <br /> shoutd bewme stIjsct to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those-provisions. <br /> WARNING:.FAILUR9 TO,SECURE WORKERS'CoMpENZATION COVEP-f►GE 1S e3NLAWt"UL,AND SHALL 5uwf-C7 <br /> ANt43yF{,O'f$12 TO GRA MAL FGHALTIeS AND CM FIl'tlaS UP-to atvtr i4tJN FtEv THOUSAND DOI-Lints <br /> (3lflt),04a,};lii AQOI? ON,Td-TjjYe.COST OF COMPENZArOH,lH'I't_REST,ATTOFtNgy,s FEES,ANI)0AMAGp_3 AS <br /> PRONfp-�ECY FOR IN SEC-t7f 14..3705-OF TNF.LABOR CODE. <br /> ^ <br /> 1•- rWJ.s �'"� -1"Lg �Aex s (C-57 ttcansad,autfeortwd rsA{rrsarltatrv�),hrreby ' <br /> aestheat�Iz�e <br /> to%W"this San.,JOaquirr Oov"ty Well Perm t.Application,on my kiohaH. i understarsd this authorteation is valid for <br /> Goo 0Years and Ir*l 04Wd.to the work Dian da*4 on fire front page at arts apolieaudn. <br /> 5-17.20401 MI <br />