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j <br /> • I <br /> i <br /> San Joaquin County.Environmentai.Health Department Unit iV Wolf Permit Application Supplement <br /> JOB ADDRESS., '�C� C t� — i <br /> r� pERiIfI1T SRS: <br /> LICENSED CONTRACTORS DECLARATION {LCD) � E <br /> thereby.affirm That I am licensor!under the provisions of chapter 9(commencing with Section 7000)of Division i <br /> 3 of the 13usiness and Professions Code-and my license is In foil force and effect. i <br /> r , <br /> Lioense#; 6 3 6 3 8 7 Expiration Date: ... . f j <br /> r <br /> Date: Contractor; Pxecisi on Sampling,.,Inc, <br /> Signature:K+ ... Title, Location Mainager <br /> Printed name: Br <br /> atacla Crawford <br /> WORKERS'COMPENSATION OECLARATiON l f <br /> I hereby affirm under penalty'of perjury one of the fo{lowtng declarations; (CHECKONE) 1 <br /> _ I have and will maintain a certificate of Consent to SalMnsure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,:for the performance of the work for which.this permit Is issued, <br /> •X—I have and will maintain workers'Compensation Insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation Insurance <br /> carrier and policy numbers ares. <br /> Carrier-fibexty outrual Insurance Policy Number:WC1137107233902.7 1 <br /> .1 certify that in the performance of the work for which this permit is issued,i shall not-employ any person in 1 I <br /> any manner so as to became subjeot to the workers'compensation laws of California,and agree 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 /> Expiration tate: 6/_302008 Signature: <br /> Printed Name: <br /> Brenda. Crawford i <br /> WARNiNG;FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1$UNLAWFUL,AND-SHALL SUBJECT <br /> AN EMPLOYER T0,CRIMINAL PENALTIES ANU CIVIL FiNES UP TO ONE HUNDRF-i3 THOUSAND DOLLARS f <br /> (5144.000.),IN ADDITION TO THE COST OF COMPENSATION,_INTEREST,ATTORNEy'S FEES,AND DAMAGES AS <br /> PROVIDED FOR1N SECTION 3706 OF THE LABOR CODE, <br /> } <br /> AUTHORIZATION FOR,Q THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC•87 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Wali Permit Application on my behalf. I Understand this outhorizatlon Is valid:for ' 1 <br /> one(1)year and is iimIterd to the work plan dated:on the front page of this apptieation. <br /> ti•29-42/MI <br /> 1 <br /> EHD 29-02.001 <br /> 6/22104 <br /> i <br /> i <br />