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FRO11 West Hazmat FAX N0. 19_66388613 Jan. 18 2002 05:21PM P1 <br /> 01/18/200? 13:52 209.1 G7_ d <br /> AGE STfiCk,f nt l PAc;r 02-1/02 <br /> ORIGINAL <br /> San,Joaquin Gawnty Fnvirgilmentai Ffealt ,Sen,icss. it i <br /> UnV WeII parr<,jt 1( <br /> JOB ADORESS. �U r �' s1. .Ap ca$an 3u- pp(emnnt_ <br /> rv► )-I-1 PERMIT SR#.- <br /> LICENSED CONTRA Tons DECLARATION LC1� <br /> I heraby affwm that I am)i, r,s under the prclvts ans of t:llflpter 8(camrne;tcin w' <br /> 3 of 11to 8USInr9G3 and f mfessions Code and my I se is in fWl force and affect, <br /> �t1 Section 70Ut1)of Utviai0rl <br /> Lfcensa J1: <br /> .._......,. ._S,".,L.�. ,Exp)u�klon Qa�te• D <br /> d <br /> SI netu <br /> Titled/M-���I t_ ,rr✓. � <br /> Prfntad ne <br /> WORKMS, Com ENSAn0N DECLA"TION <br /> I heireby of ni tinder penalty of pin.dury one cif the Ilowint de�clambort•;: (CHECK ALL THAT APPLY) <br /> I have and will maintain a t:ertlttctite at ronsPn to salt-nsure for workers'cart Ipmtsatiun,8s prnvided for by <br /> Section 3lUD o1 tho Lobar C;et�e, for tJte perfa ;Inca t t the work fnr which this permit is tssuad. <br /> x_ I havo rind will nibintaln workers,cnmpenaatin insurance,as required by;;ectivn 3i'W of the i.,3bar( odn, <br /> for the pnrfarmence of the work ror which this mit Is iusutxi. My workar r'rnmpeanstiart irisurartcu <br /> c>3rriar and poli y numbers are; <br /> Carder._ _S ��c+S - Policy Number. <br /> XI Garttty that in the performance of the work for hich this T — <br /> any manner too as to�ieCorne Subject to the p�r►nit is lsSurw'l, I shall not�riplay M1y person in <br /> shoulrJ trexome suh)'ci to the wrrrker4'c:ompe tion prpvisronripanisali tiat Section on lows ;�7Ot) � h rc e,�)ehrtll <br /> tnrthwith,amply with those provlwlans. <br /> Date: Signature ._ u <br /> Printed No a U!lYtd /9• __ lrfr%_ _ <br /> WARNING.FA)l URE TO SECURE WORJ<ERS'COMPS' SATIQp C:OVF?►'ZA�l5 UNLAWFUL,AMD SNAI19t1B-IECT <br /> PROMAN EMPLOYER TO CRIMINAL w Ng1.pr;g A(un CML 'INES UV TO CStvE HUNf7RED Tttt7USAtW ppLt AR$ <br /> 00.).IN ADDITION ITIQN Tp TM OF- OF COMPENS ryON,If iTEIZEST, ATTORNEY'S FEES,AND UAMAGF3 A9 <br /> P't;;OVlpkU FOR IN SEG I ION 3'lOti qi~TTtE(,AEOR Co E. <br /> (C-47 llGensed arathurizod ram <br /> t'eP tt�dive),hereby <br /> a utharizo .�7v!a <br /> to algn this S&n Jasgirin Courrty Well wormit Appltcawil on my()*halt. I lirldOratand 614 autlwritdticm Ic vrdid 1hr <br /> One(1)year and is Nm(tod to NtM work plan detyd on th trorit <br /> pWi ae of tbtts appllcptlon. <br /> t1-17-7400/lull <br />