Laserfiche WebLink
-San JeaettrinCountyEnvironmental Health Department Unit 4V-VW-P1w3AAprpk*11ionSupplemeht <br /> JOB.ADDR-E£S: �-z' lo v W RERMT SR#: <br /> '54&Lf" 1.CA- <br /> LICENSED C.ONTIRACTO"I)EDLARATION (LCD) <br /> I <br /> I hereby affirm that I am iicensod mndw#►a-Pnovia+ons of Chapter 9(commencing with Section 7000) of DiviAicn <br /> J-W4he Business and Professions Code and my license is in full-fort e-and effect. <br /> License Expiration Date: _ L &M-0—-W <br /> Date: factor: '6ARork 09 <br /> i s,gnature: Title: __�JTQ►/" <br /> Printed name: <br /> WORKERS'MMPEMAPON 33ECLARATION <br /> I hereby affirm uncle'penalty of <br /> lae"vne of Ole flol,owing-declaratians; (CHECK ONE) <br /> have and will maintain a rerlifi=w of consont to self-iwure err worxers'compensation,, as provA for <br /> Uy Section 3700.of the LaborCtrde,Tor the performance of the work for which this permit Is issued <br /> i <br /> SCI have and wd maintain insurance, as required by Section 3700 of the Labor Code, I <br /> 4or tt+e performance of the work for which this permit is issued. My workers'rc4%geMs fir► insurance f <br /> carrier and policy numbers are. <br /> Carrier: rZ.5I" _ .. - P44cy Nizrnber: j <br /> I certify that in the performance of the work for which this.prrrnitas�ssue0, 1 Snail not employ any person in <br /> any manner so ash hb&cwPe-sut0rttc the workers' compensation laws of California, and agree that if <br /> should become subject to the workers'compensation provisions ef.Section 3700 of the Labor Code. I shall <br /> forthwith comply with those pmvistons. <br /> Date: _ _t` Signature: 24z <br /> �y <br /> Printed Name: <br /> �I1NARNING: FA)LURE TD SECURE WORKERS' COMPENSATION COVERAGE 15 JJLtLA rr:ut,-ACID SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PINALtIkSAN>iD CIWLfl'S UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ACOMN70 THE COST OF COMPENSATION,INTEREST, ATTORNEY'S FEES, ANDZ"AGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 S[GN NG-PERNT APPLICATION } <br /> 1 <br /> (signature ofC 5719aaeed iathnrized representative), <br /> i <br /> h*ndW au#weize fpri nt name) <br /> to sign this San Joaquin CaurAyWe11;4rmit Applic7ttion on cry betlatf. I vmderstand this authorization is valid for <br /> one(1)year and is limited to the work plan dated an Aha 4rarrtpage of thin application. <br /> 8-29-UT 1 MI <br />