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..� • , ,,.. •. . ie rse I Nle 60J Dadu �cwrt=anin.y•o..:,, - <br /> San Joaquin County Environmental Health Services,unk Iv well Pa..ft AppliMlon Supplemarrt <br /> i <br /> Job ADDRESS:`✓lye N.waST w �o PERMIT SRO: <br /> I <br /> I <br /> LICENSED CONTRACTORS DECLARATION ( D) <br /> I hereby affirm that I em licensed ender the provisions of Chapte-9(commertcng with Section 7000)of Division <br /> 3 of the Bus nese andrP7rofessons Code and my Acense Is In FII force and9effect. t <br /> License# r 77 1 - S I Q Expiration Date: <br /> 1� 0 C tractor QS --- <br /> Signature: _ -+�-+ , — <br /> I Title: OT P rQTt C1 n C i(Yl CA r1a <br /> Printed name: C Xl Ot N1 CA- <br /> WORKERS' COMPENSATION DECLARATION <br /> i haraby affirm under panty of penury one 01 1119 following declarations: (CHECK ALL THAT APPLY) i <br /> I <br /> I neve and wiq maintain a Certificate of consent to self-insure for workers'compensation,as provided for by j <br /> Section 9700 of the Labor Code,for the performanoe of the work for which this permit!s issued. <br /> I have and A'l maintain workers'compansatlon insurance,as required by Section 3700 of the Labor Code. III+ <br /> i for the performance of the work for which this permit is issued. My v+orkers'compensation tnourance I <br /> cam;r,er and policy numbers are: <br /> Carrier:JA /Ca, �p.7�Unt c, Polley Number o6,0p& <br /> I certify the: In fie performunce of the work for which, this permit is issued,("I not employ any person In <br /> arty mariner oro as to become subject to the wcFlue-j'compensation laws of California,and agree that if I <br /> should become sun)eict to the workers•compensation pro of Sect 3700 of the Labor Code, I mall <br /> fortnwi0l comply with trose provlslons. <br /> Date: ��. O I Slgnature: <br /> Panted Name: Ver 0. CV-,, d'\(\ q f 1 <br /> WARNING:FAILURE TO$CCU RE WORKERS•COMPENSATION COVERAGE IE UNLAWFUL,AND ShIALL 6UOJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($700,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST.ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED <br /> � FOU ( <br /> R INN SEC�TION 3706 OF THE LAiel CODE, <br /> i' �(a G p ✓1 (si9natum WCd7 licensed authonsed roprosentatire), <br /> MsDY atRnorla(prime rtvn ) <br /> ' to sign this San Joaquin County Wen Permit ty Application an my babel}. i understand this authorization Is vN10 for <br /> I one(1)yaw and K limited to the work plan dated an the front page of this application- <br /> 5-17-2001D <br /> pplication.e-17.IOm I MI <br /> 00 3VO EEPE691,60e tf:6T e00Z1v17/Li <br />