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04/36/2008 14:58 9255211494 VIRONEX 5F PAGE 02 <br /> 04/29/2008 02: 49 9253710 GEDCDN - EA5T SAO PAGE 02/02 <br /> San Joaquin county Environmental Health Depariment Unit IV W*fl Permit Application Supplement <br /> JOB ADDRESS: L960 a PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 license is in full force and <br /> effect. <br /> \_,5 <br /> License M 7` 9.2 1 Expiration Date: VS- 3`. C)9 <br /> I Date_U4 ' '�' O6 Contractor: p� 1r0(1fx <br /> Signature: -��l�G` t .l. LIA Titla: OPRCC fnCWa!5'eF- <br /> Printed name: Oj&cja 14rnarrh <br /> WORKERS' COMPENSATION DECLARATION <br /> j I hereby affirm under penalty of perjury one of the following declarations! (CHECK ONE) <br /> i <br /> I have and will maintain a certificate of consent to selfinsure far workerscompensation, as provided for <br /> by Socllon 3700 of the Labor Code,for the performance of the work for which this permit Is issued. <br /> 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!sawed, My workers'compensatlon insurance <br /> carrier and policy/�numbers are: �7 71�/- <br /> Carrier: 0 -to-.p —Policy Number, !/z !XJ <br /> I certify that In the performanea of the work Por which this permit is Issued, I shall not employ any person in <br /> any manner so as to become subject 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 Cede, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: N 91gnature: <br /> Printed Name. <br /> [�flrl (Gt �tnlarrh <br /> WARNING;FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (stoo,00s.),IN ADOI7rON TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 9708 OF THE LA13OR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (''�'��" _ (sigrnnature ofC-57 licensed authorized repressrumtivR.), <br /> hereby authorize(print name} 2kK LJt�C.sym �[ Geac4k Wfcl.1avct^'+s <br /> to sign this San Joaquin County Wen Permit Application on my behalf. I understand this authorization Is valid for <br /> on*(t)year and is limited to the wort plan dated an the front page of this application. <br /> 8.29-021 MI <br /> EMD 29.02-001 <br /> &2VO4 <br />