Laserfiche WebLink
OCT 30 2003 9: 30AM 1-117ASERJET 3200 <br /> JAN-4-1999 11:09A FROM: P� 2 <br /> 70:1 P:3/7 <br /> San Joaquin County 6mrironraHammial HeaDeparrnenl Ur Do N WaH Permit Application8upplenNnt <br /> JOB ADDRESS (9 ZSG N 00••y ", Ac!n ►r PERMIT SRw <br /> LICENSED CONTRACTORS DECLARATION "D) <br /> heroby afArm that I am Ikweed under the provldlone of Chapter 9(commencing wfth Section 7000)or 0Mdw <br /> 3 of the Business and Professions Code and my license is in full force wW effect. <br /> License#: & 67a -q d 7 Expiration Date: _ /©Z3/ 14 V <br /> Date: Contractor: <br /> Signature: Pew <br /> .; <br /> Printed name: 1'� <br /> WORKERS'COMPENSATION DeCUMATION <br /> I under penalty of perjury one of the folowkig dedarallons. (CHECK ONE) <br /> 1 Raine and wll maintain a ce"IfIcate of consent to saMdnsure for workers'compensation,as iced for <br /> pe PrOr <br /> by Section 3700 of Mo labor Code,fof the performance of the work for which this permit is issued. <br /> _I twee and wig maintain workers'00"ansation Insurance,as required OV Section 3700 of the Labor Code, <br /> for the performance of the work for which this permp is issued. My workers'compensation insurance <br /> carrier and p2�= <br /> re: '} <br /> Carrier: Polloy Number:�� qy��7 <br /> I certify that in the performance of the wont for which he permit Is Issued.I shall not employ any person in <br /> any eyonnor so as to become subject to the workers'compensetlon lews of California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shah <br /> forthwith comply with those provisions. <br /> Date: XLA Signature: ""e' YY 2, <br /> Printed Name: <br /> WARNMG:FAILURE To SECURE WIDRKMV COMPENSATION COIIERA61118UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOM TO CRMMMAL PENAL7=AM CNL FINES UP TO OW NUWRED THOUSAND DOLLARS <br /> ittN0�N0.),IN ADDITION TO TW COST OF COMPENSATM,INTEREST,ATTORNEY13 F[ES,AND DAMA"S AS <br /> PROM10ED FOR IN SECTION 3104 OF TH6 LADOR CODE <br /> AUTHORIZATION FOR OTHAN C-ff SIGNING PERMIT APPLICATION <br /> 1, "4A- (signature OIC47 Hcansed authorised reprssenlaM), <br /> hereby authadze(print nanw <br /> to sign Vile San Joaquin Cbunty Well Perntit Applkation on my beh . h understand this authorisation is vaild for <br /> one(f)yew and is lkn"d to the work plan dated an the front page of this application, <br /> 214821 AU <br />