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GE01,0CICAL TECHNICS r'caut n3 <br /> 11!@4!1999 14:4@ _____2@95385852 • I <br /> �I <br /> lh <br /> l <br /> _ Com, v ,z.7 <br /> tronrsnen 1 Nss+lith S rr[ces,Unit IV Weii Permii APt+ttcstion 8uppisment <br /> S 4uIR County En , } <br /> lryt <br /> } J06 ADDRESS: <br /> PERM{v.st#: ;I <br /> k <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the pr0v+asone Of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Suslness and professions Code and my license is In full force d affect. <br /> � n <br /> License : . ,90 Expiration Date: d - <br /> 137ts: t ontractor•. <br /> Title: P��illtJi <br /> 1 91g„etore: <br /> 1 Printed name: t^ <br /> } WORKERS'COMPENSATION DECLARATION <br /> 4 1 hereby affirm under penalty of perjury one of the following deciarations: (CHECK ALL THAT APPLY) <br /> + !have and will maintain a cert+tete of csnsent to self-insure for workers'compensation,as provided for by <br /> j Section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance,as rgquired by Section 3700 of the Labor Code, <br /> T for the performance of the work for which this permit is issued. My workers'compensAtiorf insurance <br /> carrier and policy numbers are: <br /> Carrier: <br /> Policy Number: iil411'-Fj�s� 9�rJ — <br /> I certify that in the performance of the work for which this permit is issued, t shall not employ any person In <br /> any manner so ask to become suttject to the workers'compensation laws of Caidornia, <br /> and agree that rf i <br /> should become bub}ect to the workers'compensation provisions of Section 3700 of the Labor Code. 1 shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> I <br /> Printed Name: <br /> 1fIWARNM-FAILURE TO SECURE WORKERS'cOMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO Clt1MINAL PENALTIES AND CIVIL FINE$UP TO ONE HUNDRED TM01J3AND DOLLARS <br /> ( ,00G.I ADDITION O T OFLABOR NSATJoN.INTEREST,ATTORNEY'S FEES,AND DAktAOMS AS <br /> PR0 FORIN RECTION 5766 <br /> ` 1 (C-57 hawitaed authorized representotive),hereby <br /> 4� <br /> authartsts <br /> to sign this San Josquln County Ws11 pratmit Application on my behalf. I understand this authorization is valid for <br /> one 1 year and is Nm nett to the work pion dated to the front s't a of tills a pGcarion. <br /> i <br />