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r <br /> Sari Jaaquin County ErWironMental Health.DepartMen -Unh!IV WOO Permit-Application Supplemental <br /> JOB Afi3DRES5: r„ 1=RMIT SR 9 <br /> LICENSED:.-CONTRACTOR.S DECLARATION (SCD). <br /> I hereby affirm,that I am licensed under the provisions of Chapter 9(commencing rM SeWon 70DO) <br /> Division 3 of the Business and Pr6fas tons Codp artd"my•Iic6n.se kLJO full.force and mea <br /> v <br /> Date, - Ce�rtfcaeioC . Sim f <br /> Signature. T€tl CA�'7 JI <br /> Print Name; <br /> WORKER'$COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perju y orie of the`failo ing declarations;(check;one) <br /> I have and will niaintain a cerafkate of Consent to self insure for workers'compensation.6s <br /> provided for by section 3703 of the labor Code,for the performance of the work for which this <br /> permh is issued <br /> .I have and will maintain workem,wmpensation insurance,as requfred by Selsdon 37700 ethe <br /> Labor Carie, for the perrormanre of the work for whiGt this perrt'i>!t.is Issued. My Wort ere <br /> compensation insutence.carr*r and pc►licy,numbers are, <br /> Carrier; pt4akn4 upi .-:..Patic,y'hluriil5er C. . <br /> cediN that in the peffoitwri qf-thOi work-fghwhicltAitas°permit Is issued,.I shall:rant employ any <br /> person in any manner so as:fo-bewme subjecit.to the workers'compensation law 611 Cal itamie, arid. <br /> agree.that If I shouid become-subec€to workers'oompensatidn prow sionv of cf on'3 ,00 of the <br /> ,_shot Cade, I$hall forthk- tt.compty with lhosmprga s'tbrts, <br /> Exp, Date:, 101301.2-0!.2. _ / ,_Signature.. , <br /> PrI-rit Name: <br /> WARNING,FAtLURE.TO SECURE I;rORi{ `COMPERSATION COVERAF£tS UNLAWFUL,AND SHAILL SUS ECT.AN EMPI.OM TO <br /> CRIMINAL PENAL'IIES AND CIVIL.Fly UP TO$100.000,IN AtD.GMOH TO T"F-COSf Or COMPEWSATFON,l `E1xEST. <br /> ATTORN""Win.A140 DAfitAGEB A5PROVIDED FOR IN aCmO►i was OF TRE LABOR C00F_ <br /> I, r <br /> zATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> -- --_- _ (sig afL ai C=57 Iirlsed authorized represerstative)t <br /> hereby authorize(print name). � 11 <br /> LCs <br /> sign this Sart Joaquin counter Will Permit.Application or)my behalf, 7 uriderstand this-authorization is valid <br /> for o"year and is limited to the-work ptah-doted on Me,frrrnt page of'thls.I�pplicatiaan., <br /> l .Rr7�fgsrl►� <br /> i <br /> 1 <br />