Laserfiche WebLink
rdaol <br /> 08/04/2006 FRI 07:12 FAX . /} �(• <br /> -_.San Joaquin Gounty f�nvirunnr�? �=alth De,arfr�nt Gait IV VJe.11 t'ennit ApP;iDtein�rs Supp <br /> 'PERM-IT <br /> JOB ADDRESS: . r � <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> oftneydfirm 9us ess and n lotessio s Godetandroy 5100$of licvIS ense islinfull rforc�n�d�f�ct witjh�Sect n 7000)of[?ivisien <br /> L4 EY, <br /> r .Contra an ". <br /> Dom" t <br /> p1{oa,tt namo: y <br /> WORK�rzs' COMPENSAf1 DCCLARILTION <br /> 1 hereby affirm vndrr penaltY of perjury One,of the tollowr Q dcdaratioris: (CHI=CK QNE) <br /> I have and will maintain a cntificste of con^">enl to setf 4nDr'e for <br /> wodceri compensation.7s providx for <br /> y"by Se and'" <br /> 3700 d'fne Lahor Code,for tile perForrronce of the Work for'n't'$eGroi ii cn 3700tuf Ir e,Labor Code, <br /> haueand will matnfaimwodceia �anPen.,atron insurance,as required Gy' <br /> for theparfo�trt,��nnce oftltFs forwhich this pem'iit is issued.' MY worf:crs/'�r,OmP°n(s�al'an insurance <br /> can or a 'w^'9Y nUln �Hfc: <br /> Policy NumLer_ <br /> Cattier:` b an rson in <br /> Mori tante of the worN.for whlcl?this,permit is issued,f shall not employ my ht f if <br /> I certify thatin the Ps an a Of,t�t to the or rkersr onipatisaItion Uwr of Calitomla,aril eg <br /> any mannef so as to�ro a workers' thin WG se.on Pra inions rb Section 3700 of the Labor Cade,I shall <br /> should become 5 ttiose PrMs�s� <br /> forthwi G F>IY �. <br /> �Signatttre:_ ` � n � <br /> Date:_. _ -- <br /> printed Name: 51� <br /> WARNING:FAILURE TO SECURE 1NOMC-RS'COPoIPEMSATION COVERAGE IS uNLAVUFUL,A ❑ OLLA <br /> DAARA.ffiu3Jt-CI <br /> GES AS <br /> AN EMPLOYER TO Cl21MINAL PENALTIES ANDIV <br /> CIL FINES UP YD ONE NUNCIRED'n IOU'AND DAgA <br /> (Si 00,000.),IN ADDITION T4 TFIE C05T OF COMPENSATION,IN 1•ERES7,j'TTORNEY'a FLEE,AND <br /> PROVIOED.FORIN SGC170N 2706 OF THN LAHOR'GOD`' <br /> ( • p THA POW SIGNING PW AFFLICATION <br /> AU <br /> TIK- RI A7iE C `-' . <br /> _ � —1^r n turd Tilston 7uthotited roNresenSslfJVah <br /> hom-bY AUtl'IOI&C(print name) <br /> lhls 9na. aq:dr<Cn!rnSv V:u!{Pa,mit Cntf�+r?t;rrtd th is <br /> 4;ant¢r+,a-athe -.f:�rd Sor <br /> c-rOr. " II <br /> i r n.a,rel i,:IC'rlfed o.r f?,.�a,.�r};pl,r,i i:ezwrtar, it;e•xon; pa.-'.' i <br /> rat ... .. .. - :. <br />