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071ZU2010 17:03 Advanced 1p,-gnvirctlTlRrltal Inc. 'rM=4671118 A.0051005 <br /> V <br /> San Joaquin County Environmantal Hortlh [lepartmgrlt Unit IV Welt Fermit Application Supplement <br /> JOB ADDR9$8; PERMIT Sfi#: �?)—C3 <br /> LICENSED CONTRACTORS DECLARATION ( Qpj <br /> I hereby affirm that I am Iicenaed under the provisions of Chapter 9(commonang with Section 7000)of Division <br /> 3 of the Business and ProfbWons Code and my ifcansa Is In full force <br /> License# $�(6--lExpiration Date; 7101 <br /> �7 !f <br /> Date: 1 10 Contras V 9xv +� I <br /> N1 1 <br /> Signature: <br /> Pontod name; <br /> WORKARS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of penury one of the followirg declaratiorw (CHECK ONE) <br /> I have and will maintain a cerUcate of consent to self4rigure far workers'mmperrslatIoit,as prodded far <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. <br /> I how and will maintain workers'mmpensatlon Insurance,as raquired by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit Is Issued. My workers'compansatlon tnsuramm <br /> canfsr and policy numbers are: - <br /> Carrier. Policy Numbor. <br /> I certify that In the pt. %mwnce of the wctk for which this permit is Issued, I shall not employ any prsrson in <br /> any manner so as to beaon'O 8018ct to this w8ri m'compensation laws of CaMbrmis+,and agree that if I <br /> should become sub)ect to the wcrkars'compensation prafton9 Section 3700 of the Labor Code,I shah <br /> forthwith comply w�+those provislons. <br /> expffatlem no": 8lpneture: <br /> Pi i:nted Name, S <br /> wARNINO:FMURE TO SECURE WopKS tS'CompENRATION COVERAGE 18 uNLAWFUI,,,AND$HALL SUBJECT ' <br /> AN EMPLOYER TO CRIMINAL t a"TIES AND WIL FINES UP TO ONE HuNtDRrab THOUSAND ip01.1.11rtS <br /> (4100' D FIN ti!?INS DON To TW 3708 OFST O LABOR id NBATION,lREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> DE <br /> AUT N FORQ THAN C-67 SIGNING PERMIT APpUCATION <br /> (slanaturs OM47 liasne*d nuthm""r�pre�r�taehrsl, <br /> horaery guthorizo(print rrstera)_ 1"� ,I*'1�CY�1... [1IYJAte� <br /> to sign ehla son JomgWln county Won P&MR Appllneilan On nay ltshalf. r trndgratarrd this e�t#tltdrl�atlarl is valid far <br /> ane(1)year and Io flrnh"to the work plan dated on the front pftie of this oppltcatlon. <br /> 8-amx 1 M1 <br /> fitpR 2q.Q�Ob1 <br /> 6124104 <br />