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JUN-02-2009 TUE 01 ; 14 PM PC Exploration, lnc. FAX No. 916 434 4206 P. 003 <br /> 06/02/2009 12:45 18314434845 OFFICE DEPOT PAGE 03 <br /> San joaquin County swirorim i Health Department Unit IN Welt permit Application Supglenentai <br /> JOS ADDRESS,. tf� PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION C <br /> _ _, .. .... l hereby alfirm;that l am licenged,under pravisions-of ChapterR(OOMMendngVAth S��tion 700 �aT <br /> Division 3 of the Business and Profeaeions Code and my license is in full force and effect. <br /> license S: Exp Date: L - <br /> Date_ Contractor. <br /> $ignatu Title: — f <br /> Pmt Name: <br /> WORKEf;rS COMPENSATION DI=CLARATION <br /> I hereby affirm under penalty of pedury one of the following dec)aratlons:(check.ono) <br /> 'I fteve and will maintain O. to of consentto selfoinsure folr wo w compensation,as <br /> prodded for by section 3700 of the labor Code,fat the perfOrMance of the work for which this <br /> ® permit is issued. <br /> . e 'have and wili maintain workers'compensation insurance,as required by Section 3700 of the <br /> Labor Code,for the performance of the worts for which this permit is issued. My w+orkarV <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: sdJ ,,T Policy Number <br /> I certify that in the performance of the work for which thie permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of Caltfomia, and <br /> agree that If I should became subject to worker's'compensation provisions of Section 3700 of the <br /> Labor Code,I shall forthwith Comply with those provisions. <br /> Print Name: <br /> WARNING:FAILURE <br /> CRIMINAL PENALTIES ANWORKERS! <br /> CIVIL PIN TO$100,0TION 00,IN ADDITION TO Till:cosi LAWFUL�AND oP COMPINSAT10N,INTEREST.�® <br /> ATTORNEYS FEES,AND gAMAGES As PROVIDED FOR IN SECTION 3M OF THE LAOQR CODE. <br /> 5 K t <br /> . <br /> AUTHORIZATION EORTHER THAN C-67 ;SIGNING PERMIT APPLICATION <br /> (Signature or c.57 licensed authorized representative), <br /> hemby PuMarlm(print e) /°t7f VW- &.Aid ,to <br /> n J aqutit cb .. . It Application on a -i un and this a ori on is valid <br /> -ellin#0 r for one year and is limited to the work pian dated on the frow page of this appilaatl4n. <br />