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LOo �� ��/I/* pe� <br /> 74 ,b E�, /r <br /> San Joaquin / <br /> quip County Environmental Health Department Unit IV Welt per7Senp700o)en0'fa' <br /> Su <br /> JOB ADDRESS: �` PE RMIT SR# ��plementalLICENSED CONTRACTORS DECLARAD)I hereby affirm that I am licensed under the provisions of Chapter 9(commetion 7000) ofDivision 3 of the Business and Professions Code and my license is in full forLicense #: qo6 8Y5 E xp Date:Date: Z Contractor. �� Cr <br /> Signata;L—. Title: N--Ms"-�. <br /> Print Na e: <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> _ I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by section 3700 of the labor Code,for the performance of the work for which thi s <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier an d policy numbers are: <br /> Carrier: S�4'0- La Policy Number: o S*Jr - '\Q <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'c ompensation law of California, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith com ply with those provisions. <br /> Exp. Date: f -_(C/r/f Signature: .— <br /> �— !� <br /> Print Name <br /> WARNING:FAILURE FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100.000.IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FO �R THAN C-57 SIGNING PERMIT APPLICATION <br /> ��- (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Perr ,S L ,to <br /> sign this San Joaquin county Well mit lication on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> AI2910111Y <br />