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06/19/2000 03:30 925-46559 ATC PLEASANTON 9--OS 4 5 1 FILEDOPY4 <br /> Jun 18 O1 04:20P n Jones <br /> I ill/20RP 03'23 925-4c3-25 3 ATC PLEASANTON PAGE 05 <br /> Sin Joaquin County Lrfrviranmsntil Health><uVSUV.,unit N wan Permit Application Supplem&nt <br /> JOQADDRESS: /-O:_ PERMIT Sft <br /> LICENSED CONTRACTORS 13ECLAMTI0N LCD <br /> t hereby Af&M that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of int Business and Profa"lons Cade And my f4w"is in full fort*sad effeCL <br /> (.kens•Oi (n�?3� e S E q*alion Data LIN -05 <br /> Date: (nV I L Contractur: F-1V-Qn <br /> Signature: _ _ Title: _6WIU , <br /> Prints+;(nanw t d Ft�.N <br /> WORIMM C011AP&MT10N DECLARAT10Fl <br /> I hereby affirm under Va+asty ar per"one of(tie fagowing dederatioms: (CHECK ALL THAT APPLY) <br /> 1 nal v and will maintain a cerldicOM of Consent to$864 sur1l for workers'oornpf•V850n,03 Provided for by <br /> Sectlon 37W of the Labor t:'.oft for the perfomsanco of the work for wNfch this pwmk is issued. <br /> Zj have And will malnian workers'wmponsatlon hu wWws,as mqutred by Seetlon 3700 of the Labor Cod*, <br /> for the parkwmanee of the work for which this gamut It lcswd. My workers'oorrlpensstion IrtsutAnae <br /> carrier and policy dumber*ere: <br /> camor %•l•,snrAT AouayNunlLw_ IS36zzoS-oo <br /> 1 wi fy that In the Wom anco of dr*work for whidr mis pwrnl is isauod.t shall not employ any penton M <br /> any rnaltner so as to bet xna subpd to the w0rkor0'companS3WA laws Of California,and ague that If I <br /> should booms subjed to the wattcors'co npensabon provisions of Section 3700 of the tabor Code.I shall <br /> fatnwith comply with those provisions. <br /> Dsta:� �'Q� _ Signature: r-1 y l�--t_ <br /> Printed Nam. .1 VJ` qs -4 <br /> WAPMWQ:FAMUge TO"CURE WORKsgV CONIftNSATIGH WVERAGC IS UNLAWFUL,AND SMALL 3UBJBCT <br /> Aid 1°J( WYF.RTO CRIAPIAL PW"LM AND Ctft FL4M UP TO ONE HUNDPW 7ti0 4AND DOLLARS <br /> (310.OM) gN AD r MGN To tM osOF j O CompSN" <br /> 000IWIL(1�177EMST.ATT0RNrV%IEEE.AWd WWAC i4 AS <br /> I a�L eco _ _ (Wgnatwo OIC-V ncwwod Awiloeirod mwesentauwmh <br /> hemby rwthorias(primto sign this San 3oagwn Rourft Will Pal +ltAppikaWn on vnyb"E 1 understand this sufhorizasietl Is valid for <br /> err(1)year and Isdlrngsd to the work plan daWd on tfw front Paye of V"appllw0wh <br /> 5.17.2000/MI <br />