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u4'/uJ/VL F711 16:01 FAX[ old 7,900 URS cog <br /> 89/03/2002 13:09 20946934W FIFTH FLOOR � F I1L E ��1 <br /> � <br /> Ban Joaquin County EnViton wl tall HealthM1iees,unit N Wall Permit Application Supplement <br /> JOB ADDRESS' Z q 1 PERMIT SFtO:__ <br /> LICENSED CONTRACTORS DECLARATION (LCDI <br /> I hereby a`flm.that I em Ileensed under the prorlslons of Chapter 9 (commencing with xiu z)irgij4ibn <br /> S of tro Business and Proofeyssion® Code and my license Is in full force and effed <br /> en !;-613 — <br /> Llesa 0: 17-406 �-Og -_ Expiration Dalw; S/-31 <br /> Oate: S o Contractor: TEG - /Uot>•T9r"2RrJ «t•tf�utJt�s„ C. <br /> SlBnaturo: ��� Alf _Title: <br /> Printed name: is1a4l2f'C J£f2 PQA k' <br /> WORKER&' COMPENSATION DECLARATION <br /> thereby atflnn under penalty of perjury one of the following declarations_ (CHECK ALL THAT APPLY) <br /> I hour and w0l maintain a cer0(lretc of consent to self-incurs for workers'compensation,as provided for by <br /> Section 3100 of the Labor Code,for the parformanins of the wont fw whleh this permit is issued. <br /> -y--I hart and will maintain v rkrrs'campensatWn insuonce,as required by Baction 3700 of the tabor Coda, <br /> few the porformenm of the Werk fat which this permit is Issued- My workers'compansatfen ineurrrce <br /> ®slur and policy numbers atr:. <br /> carrier: '�7R7fc f=cAe./ Policy Number. �1 6606$ 7 <br /> i <br /> _I menry Viet in the performance of the work for whldl this permit is istaled, 1 shall not employ any person In I <br /> any manner so aa.to became subject to the workers'corn pensMion laws of Calilbmlo. and awwe that if I <br /> should became subject to the workor6'compnneetion provis"iono of Section 3700 of the Labor Code, I sha11 <br /> forthwith comply with those prouislons. <br /> Dabs:_ O� Slpnsture: II <br /> Printed Name: PSA <br /> wARNIN6:FAILURE TO SECURE.WORKERS'COMPENSATION COVERAGE IE UNLAWFUL,AND SMALL Sual <br /> AN EMPLOTIRTO CRIMINAL P9014ALTIPS AND CTRL FINES LIP TO ONE HUNDRED THOUSAND DOLLARS <br /> (SID0,000J.IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEMS FEES,AND DAILADES As <br /> PROVIDED FOR IN SSE�EC,TIOO�N9706 OF THe LABOR COOB- <br /> 1,�(f.7W \- (alpnstun 0=47 11'a,twed authorised repressntatire), <br /> hereby authorl"(pr nt narnall__. : 'Z <br /> to sign i tia San Joequln Ceumy Well Permit Applloatlon on my behalf, t undersbnd ous mthmMatlon is ralid fur <br /> one (1)yasr and is limited to the woris plan aced an the front page or ilre application. <br /> woo! <br />