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FROM.: West Hazmat FAX NO. : 191663E6613 Oct. 03 2002 06:51AM P1 <br /> 10/02/02 *D- 14:36 FAX 1 9111.1 0430 SECUR-SAC:RAMENT0 * Qinn <br /> San Joaquin County Environmental Health Sorvioes, Unit IV Wall Permit Application Supplement <br /> JOB ADDRESS: </l_Gr1 G /��1 _ PPERMrr StR#: .....,,,_____� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed undut the provisions of Chapter 9 (Commencing with Section 7000) of Ulvision <br /> 3 of the Business and Professions COdu and my license In In full toro9 and eltert. <br /> License rt $--s 7 5 Expiration Date. 8 r'j 7" 0 3 <br /> Date. Contractor: �� r �yfLa�^r_ 6.0 ce-1 <br /> Sionnture:t� —� �....'. .---„ 7iUc /! rQ r a�l-ems (,t/(.�..+7Sc 7� <br /> tel. c.{-moi a � <br /> Printednallt�_L..-,._. J1LJ/�fa.ctv� <br /> WORKERS' COMPENSATION DECLARATION <br /> I herehy affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _ I havo and will maintain a cerlificate of consont W salt-insure for workors'cornponsation, as provided for by <br /> Section .17011 0l the Labor Code, for the performance or the work for which this permit is iusuad. <br /> have and will maintain workers'compensation insuranre,as required by Section 3700 of the Labor Codo, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurElrtoo <br /> carrier and poli numbers aro: <br /> Carrier: �r r r GLL ✓J a a- UJ 4u 6 R Z?Y / <br /> —_ Policy Number: <br /> _,. I oonity that in the performance of the work for which this permit in iseuod. I shall not employ any person 1n <br /> any manner so as to becoma subject to the workors'compensation laws of California, and Li"Anal it i <br /> should beromo subject to the workers'cumpensation proviuiuns of Soodon 37 .aYxor Code. I shall <br /> forthwith comply with those provisions. <br /> Date: /o -0 3 0 'Z Signature:K <br /> Printed Name: I------ ir rFir+.s 14' <br /> WARNING:FAILURE TO BE-CURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN CMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION.3706 OF THE LABOR CO,JE,r--- <br /> ficensed authorized representative), <br /> here arnnorize(printft <br /> to sign this firm Joaquin County We P mit Appticon my behalf. I and®rsland this authorization is valla for <br /> one(1)year and is limited to the work plan dated an floe front page of thin applinaeon. <br /> s-17-20001 M I <br />