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• 1 <br /> N0.102 <br /> — —"-- CLAYT OUP + 1H31662H179 , <br /> 03/17/2005 15:02 <br /> San Joaquin County Environmental Health DopaA(ment Unit IV Wall Permit APP <br /> Iicatlon Supplement <br /> PIT SR#: <br /> JOB ADDRESS: ERM <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> isions of Chapter 9 <br /> commencing with Section TWO)of Division <br /> 1 nereby affirm that I am licensed undarthe Prov <br /> 3 of the inesy antl Profe sons Code and my License is in full force and e0ec1. ,110 <br /> M- ( '—}--i/-q�gyfl__Expiration Date: <br /> 9(� j <br /> Liconae ff: ''1-"f�' - <br /> `> Contract �I �O�J4M"` n <br /> Dale: `I f <br /> Title: <br /> signature: <br /> PAnted name= <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty Of pedwry one of the following declLrations: (CHECK ONE) <br /> mpensation <br /> I have by Section Wit 3700 maintain e Labor fficaliti Of ccCode,for lhesperiorrnaenl 10 oce of the work for Whl-InsUrC for workers'cehthis Penni is issued, <br /> ed for <br /> �I have and will maintain workers compensation IraWance.a3 required by Section 3760 of the Labor Code, <br /> for the performance dvjill maintain <br /> of the wotk for Which thle permit IS Issued. My workers'compensatlon Insurance <br /> carrier and policy numbers are: �/ SCE Z(_p <br /> 5 nin Policy Number:Carrier: <br /> Carrier: I shall not employ any person in <br /> s P and agree that if I <br /> I eeRlty that In the performance of the work for which this permit Is issued, <br /> any manner so as to beodme subject to the worxers'com ansatlof taws of California, 9 <br /> should become subject to the workers' compon5all�rovisions of Section 3700 of me Labor Code,1 shah <br /> forthwith <br /> comPlY with those provisions. <br /> Enpiralion Date: l( Ub Signature: W�L <br /> Printed Name: <br /> E IS UNLAWFUL,AND SHALL <br /> DOLLARS <br /> 775 <br /> FAILURECT <br /> CTR MU1AL PPENAL.TtESRAND OI L FINES UP TO O�MpENSATION HUNDRED T 5 EES,GAME)DAMAGES AS <br /> YERTO <br /> FORH SECTION 3706 OF THETO THE COST LABORCODEION,INT <br /> THORI ION FOR OTHE THAN C-57 SIGNING PERMIT APPLICATION <br /> > (signature OIC-57 llconaodffle a(print name) Crag, P���_ r�'�'�t�I�aWell Permit ppplicatlon an my behalf. I understerd this authorizatlon Is vaNtl for <br /> s San Joaquin County a of this appteatienar end is limited to the worx plan datod on ma front pa9 MI <br /> END 24U1-0Dr <br /> N2'JO4 <br />