Laserfiche WebLink
11/08/99 MON 14:50_VAX .916 858 0605 <br />IA 141e1ft0 <br />11/06/09 FRI 18 -35 FAX 918 858 0603 <br />Z] 003 <br />Nov. 08 1999 1e:29Am P2 <br />IT Corporation/RC 002 <br />IT Corporation/RC <br />FAX NO. : 191663E10613 <br />San JoaqUin CountyEt Ivirontriental 'Health-Services, Unit IV Wrill'Perrnit APPikation Supplement <br />JOB AtIORES:11C)D C. y1 /4T„Jj.r i-rt, Ave. • putf,1117 <br />LICENSED CONTRACTORS DCCUkRATION (LCD) <br />I hereby sf6rm that I am licensed under the provisions of Cheptwr 9 (commencing with Section 7000) of Division <br />3 of the BLE5irieli and Professions Cade and my license is in full force and effect <br />Expiration Date: I Zoo/ <br />Tine: "Jo Ofts-or...2.6,4,..4.. ,11410.0.sigar.--, <br />Printed nanteie —!-,41~0 A - 1,1"4443."-4.'-- iffqt4" ito/ec-e4.a_fi i- <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />feaI ve end MA maintain a certificate of consent to self-Insure for workers' C9mpansatIon. 36 provided tor by <br />ction 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />1 heve and will maintain workers' DOrnpenzation Insurance, as required by Section 3700 of the Labor Code, for the perforrnehCe Of the work for which this permit ie ISSuird. My workers clompensatIon insurance carrier arid policy numbers are: <br />Cimier. aqinaki Kr--, Policy Number: Lttiai)kl , c4x7901 <br />I certify that in the performance of the work for which this permit is issued, I shaft not employ any person in <br />any manner so se to become subject to the workers' compensation taws of California, arid agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shad forthwith comply with those provisions. <br />Date: //- S I-5- 5' Signature:J7 ::) <br />Printed Name:. ,04- • /..,4 <br />WARNING: FAILURE TO SECURE woRnFili• COMPENSATION COVERAGE IS UNLAWFUL, AND SMALL SUBJECT AN EMPLOYER TO CRIMINAL. PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS IS100.000.), IN ADDITION TO TIft COST OF COMPENSATION, INTEREST, ATTORNEY'S PEES, AND DAMAGES AS PROVIDE!" FOR IN SeiC.T4M14130 OF THE LABOR CODE <br />' 4 <br />(C.117 licensed authorized repriasentativs), hereby <br />ei/t) <br />to Egan this then JosquIri count/ WWI Permit Application on my behalf. I under:um:I this aUtharization is Valid for <br />one 1 ear and 'hailed to the work ban dated on the front of this <br />'kens. it: STY 97 <br />Clate: /yr -TP Contractor' <br />519nalu