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ti <br /> FEB-26-2001 09:41 FROM:TWINING INC. �1559.266 7126 TO 4683433 P.0021005 <br /> x86=6 S00:3cJHd 'ONI '5 INIM1(O ££$£li`Jbbb l wVvv'uu 'w"- "' ...�. <br /> San Joaquin County Environmental Health Services, Unit IV Wall Permit Application Supplement <br /> JOB ADDRESS: 300 PERMIT SR#: <br /> DD2s3� � <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is In full force and effect. <br /> - ,Q <br /> License#/G�C� 1 ✓ W,5:9 r�^ Expiration Date: , ��• <br /> Date:lf; `• "" 0/--- - -Contractor: . / WwfAh� <br /> Signature: y Title: flew. �.- <br /> 1A Af <br /> Printed name: r"` �� <br /> WORKERS' OMPENSATION DECLARATION <br /> I <br /> I hereby affirm under penalty of perjury one Of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> r Section 37DO of the Labor Code, for theiperformance of the work for which this permit is Issued. <br /> have and will maintain workers'compensation Insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: 51—A E FGAJO Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that F I <br /> should become subject to the workers'Compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date:ar jr Signature; <br /> Printed Name; <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,-AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> {3100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> 1 (C-57 licensed authorized representative),hereby <br /> authOriZe <br /> to sign this San Joaquin County Wall Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of thls application. <br /> 5-17.2000/MI <br /> 50 39tld a007A HiJId 6£pea9DE0Z Lt,:80 L00L/9Z/L0 <br />