Laserfiche WebLink
2-21-1995 6:08A1.1 F POM P. 3 <br /> + i <br /> 87tif 3.:�r 1 ff�i i:i:d7. lEs9� � afrSTi3 ATC, <br /> Sam Joaquin County Envie nmentai Health 5drvices,Unit IV We Permit AppRcativn Sufspiernent Y� <br /> JOB ADDRESS: - PERMIT SR#: <br /> LICENSED CONTRACT01S DECLARATION LcD <br /> j <br /> ` f hereby Wrrm that t am licensed under the provisicns.of Chapter 8(commencing with Section 70Q0)of Div�siors <br /> 3 of the C�ussnriss:aria f'rofess{orts Cede and my license is in ftdi force aM effect. <br /> s <br /> License 0: ' <br /> �p�atiar4 c��t �. <br /> Date: `a __. Contractor. <br /> Slgnature, Tula: Ems- <br /> Prin od name: <br /> WORKERS,COMPENSATION OECLARATION <br /> i hareby affirm under p"ty of perjury orie of the foncyvIN deetmatiOnS.' (CHECK ALL.Tf-fAT APPLY) <br /> 4!tsa�e arid will maintain a cerificate of Gvnserrt to seti nsurs for workers'.compensaborr, as provided for by <br /> Section 3704 of the Labor Code, for tho performartre of me work for which this permit is issvec_ <br /> 1 �f have and will Maintain wor!wvs'cornpensatkm inx=nce,as required t)y Sec'Wn 3700 of the Latyor Coda, <br /> for the perforrrstsnca•ofthe work for which anis permit 1s issued. My warkere cornponsation#;tsuranc» <br /> carrier and lsalicy n <br /> =Aars are: <br /> Carrier: c r • Policy Number. <br /> F certify that in the performance of the work far M ch this permit is issued, i shalt not empiay any persons in <br /> any manrec$0 84 to berorne su'Dject to tine wor(ers'oom;wmation laws of Cafifatnia,and agree that if 1 <br /> should bevo"sz:1*Q=to the workers'ronspensadon provisions of Section 3700 of the Labor Code, i shall <br /> {� forthwith cotn91ywftl7 arose praovisiorss. <br /> ! Date- � wU� �Signature <br /> o- Printed Name: 1(� <br /> WARNING:,FAILURE TQ SECURE WORKERS'COMPENZATION COVEF+AGS IS 111V1A1fVFUl,AND SHALL 5t3d tECT <br /> AN INF'L OYER TO CRIMINAL FSNALTIES ANE]CN ?L FtheS up To ONE N#.'WIREP THOUSAND DOt-LARS r <br /> IN A00111Otti 170 THE COST CSF cometNsAilCli,IN't'ERr33,r,ArrOANVY'S I+EI~S,AND DAMAGcs AS <br /> PRCMOE 3 FQR IN SECTION 3708 OF TNF_LAaQR CODE. <br /> �•-.. �`�1 � ��n ���-� �(t:-'S7 f4csnrs+ad auihotized reprs3eltttltirv},ha^ab I <br /> acthorlxe <br /> to!fan this San 4051quirr 00"Well Parmlt Appilusntlant on my k*haif, f understard this authorization is valid for <br /> oaa 0j year and is titrsited to the work Plan etntsd an the front page of this appiteauon. <br /> V <br />