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Jun 24 02 02: 15p Wayr4 Woodward 1 -70'7-374-5677 p. 2 <br /> San Joaquin County Environmental Health Services,Unit.N VkH Permit Apprication Suppknvmt <br /> JOB ADDRESS_PGIE S w.sa r S1--b o6 H PERMff SR#_ 003C)2-01 <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <br /> 1 hereby affirm that t a n-r- '-—d under the provisions of Chapter 9(cvmrneac i g with Section 7000)of Mvision <br /> 3 of the Business and Prrootessions Code and my license is in fufl force and etTert. <br /> License tt C -57 700-71t mon pate: <br /> Date_ 2y= 0 conyactor WooOuJ ARA 0?JLLIF <br /> Signature: Title: O PE e^Tfaty% M l4N+A G GTR <br /> Prk*ed naaw Er-lK F04SS?�0-N <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby of y rf under penally of perjury one of the following worm- (CHECK ALL THAT APPLY) k. . . <br /> I Have and will maktain a certificate of consent to stere for workers'compensation,as provided for by : <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued- <br /> 1 have and w7 maintain vw kers'compensation insurance,as required by Section 3700 of the Labor Cotte, <br /> for the pedormance of the work for which this permit is issueworkers'Wmpe-safivn insurance <br /> carrier and policy numbers are: <br /> Carrier: S TATE F-Lmid Policy Number 00 202.5 S 1 <br /> i' <br /> _I certify#%at in the pwforrrmance of the worts for which this pemhit is issued, 1 shall not employ any person in <br /> any manner so as to became subject to to workers'mon laws of California,and agree that if I <br /> should become subject to the worloers'compensation provisions of Section 3700 of the Labor code. I shati <br /> forttrwitfh comply with those provisions. <br /> Onto: Signature: <br /> Printed Name: Ei!'1.0 Fd�e SST.ea-�. <br /> WARNIMG:FARME To SECURE WORKERS,coYPENSATION COVERAGE IS UNt.AWFUL,AND SHALL SUBJECT I' <br /> AN IM1 OYER TO CROMIAL PENALTIES AND CML FINES UP TO ONE MMORED THOII.SAMD DOLLARS ` <br /> (i'109AW).IN AD MMN TO THE COST OF COMPOISATIOM,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROYDED M SECTION 3706 OF THE LABOR CODE. `. <br /> L sigrr�tdume o/C 57 lirxmhaed autlmorizsd eve), <br /> ,IF a d1hartm(print nanhe) f ►a o Nva c3�t <br /> to sigh this San Joaquin County Weil Perndt Applicathm on miry belmalf- 1 understand this autlm mtraboo is valid for <br /> arta(1)yew and is tiehiE W to the work plan dated oma the froM page of this application. <br /> 5-17-20001 M <br />