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j <br /> i <br /> l <br /> San Joaquin County Fnviranr119txtat 14ealth Depar6nent Onit iV Wsii Permit Application Supplement i <br /> JOB ADDRESS: C o �eAC .,,rte ,, PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> ' i I <br /> i hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my licensa is in full forte and effect. <br /> License#: 636387 Expiration Date-_ 1 /31/2010 <br /> I,. ! i <br /> Date' ` Contractor* 2recision Sampl-ing, Inc. I <br /> Title:Location Manager <br /> Printed name Brandy_ mrd I <br /> WORKERS'COMPENSATION DECLARATION <br /> l <br /> I <br /> I herebyatfirm under.penelty.of perjury one of the following declera;ioos; (CHECK ONE) i <br /> I have and vilil maintain a certificate of consent to self-insure for workers'compensation,as provided for I i <br /> by Section 3700 of the Labor Code,forthe performance of the work for which this perm It Is issued, <br /> I have and will maintain workers'compensation Insurance,as required by Sectlon 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrior and policy numbers are: <br /> Oarrierd;ibet•ty Mutgal- InsPolley Number. CIS7.1077.339b27 <br /> I certify that in the performance of the work for which this permit is issued,I shall not employ any person in i I <br /> any manner so as.to become subject to the workers'compensation lays of Cel,66mia,and aoree that If I <br /> should become subject to the workers'compensation provisions of Section-3700 of the Labor Code,I shall <br /> forthwith comply with.those provisions, <br /> Expir2tlon Date; 6 J30f 2Q0$ Signature: "'"" <br /> .Printed Name;. Bre <br /> nda :Crawford.. <br /> I <br /> I <br /> WARNiN('3i FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND$HAlL SUBJECT <br /> AN EMPLOYER TO,CRIMINAiL PENALTIES ANi3 CIVIL FINES UP TO ONE HUNDRED'THOUSAND DOLLARS <br /> iN ADDITION TO THE COST OF COMPENSATION,INTitREST,ATTORNEY,$FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SE071ON 3706 OF 714E LABOR CODE, <br /> AiJTHORiZATION FOR 4THAN C-57 SIGNING PERMIT APPLICATION <br /> I ' ` <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize.(printn0me) r�1Jt C, . <br /> to sign this sen Joaquin County Wgil Permit Application on my behalf.]understand this authoriration is valid for I <br /> one 1 year and is limited to the work plan d <br /> { }y rk orad on the front page of application, <br /> P p g this app catwn, ! . <br /> B-29-02 I MI <br /> END 29-02.001 I <br /> 6/22roa <br /> i <br /> i I <br /> i <br /> i <br />