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FROM West Hazmat FAX NO. 19..66388613 San, 18 2002 05:21PM P1 <br /> 01/18/2002 13:52 2(79•fi.W;11b - AGE GTOCKrON tJ PAGF - 02/52 <br /> San Joaquin County Fnvirgtlmantal dealt -an Ica% Unit IV We11 <br /> "C'1�.�po P emeht� <br /> JOB ADDRESS: s r. - <br /> o o r F,EMn )4 PERMIT SRS <br /> >'a Tq.K Ill,) .� <br /> LICENSED CONTRACTORS DECLARATI 1( 'Cb) <br /> I hereby affirm that 1 am iicenaed under the pt %ft' ons Of Chapter 9(Comma,cing with 3e tion 700u)of L7lvisigrt <br /> 3 of Via Business and Professions Code and my Immse s in fWl farce and affect <br /> License/k <br /> F-xpGatlonpnte:_._G/- <br /> Date:"G/- �8' y Ca,tractm C/i/f zsa�r <br /> Slpnetu _ �• v -/ <br /> Title: oNA•r-i k-14W i51,ryt_ <br /> Printad narp t c4e st a a,t 4LIT <br /> WORKERS' COM ENSA nON C)ECLARATION <br /> I hnroby of 'ril under penalty of pedury ons of the Ilowinp derlambons: (CHECK ALL THAT APPLY) <br /> _ 1 have and Will maintain a ceitlryc6te of ionsen to self-nsure for workers'Compensaliun,as prnvided by by <br /> Section 3700 of the labor Code,for that perfon nanca C the work for which this permit is issued. <br /> X-I have and vAll maintaln workers'cOmpennatior Insurance,as required by Section 37W of the Labor-Code, <br /> fur the performance of the work for which this pwmlt is issued. My workers'compensation 1nsYlranca <br /> Carrier and poll y numbers are: <br /> Calminr,_. s ��e.d �.t+S Policy Number: aZWd✓G?Z7�� <br /> X1 certify that in the perfarmanw of the work for wfljoh this pennit is 13,,U M, I snail not®mpley any person in <br /> any manner ea as to become subject to the coo ars'C,o npensation Wws of C:t lifomia,'N aBrae Neat d I <br /> should become suhjeCi to the workers'compe ,tion previsions of Sechan 3701)retie Labor Cude,1 ahall <br /> forthwith comply with those provisions. �+ <br />' Signature �r r <br />+ PrintedN■ o•_ C///'y 40 A• - j lifr"j__ <br /> WARNING:FAIL.URE TO RECUR6 WORK;=RS'cUNAPE TtOM coVkl'IgGE ly UNt.Ayyptll„AND SHgl1 St1g.lEt:T <br />{ AN EYPI.OYP_R TO CRIMINAL PENALTIES ANO CML 7NES D{•TQ ONE HUNDRED THOUSAND I7oL1,AR$ <br /> (;i00,doa.),IN ADDITION TO T11IE CASTOR COdaPEN TION,INTEREST,ATTORNera FEE3,'AND DAa1AM AS <br /> PROVIDED FOR IN RECTION Me OF THE LABOR CO E. - - - . <br /> i �Gti!/44s <br /> _ ..__!C-.'i7.11eenmad aufhnrizec)reprisaltxefve),IWrettY <br /> 1. to-219n this$an Joaquin COunty Wen Permit Applic2dian on my Ilshatt. I tlndatetered this&Mn katim lsvalid for <br /> ane(1)year and is Nmitsd to Iles work plan dated on U#9 trait page of this appileotlon. <br /> i <br />