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Aug 10 06 09:44a David Fisch 209-772-3571 p.2 <br /> nuu. IV. [UUU 0� 3Inlri 0 "rlt tnnln ILLri flu. tib'ib f• 2 <br /> Sail Joaquin County Environmental Health Services, Unit IV Wel! Permit Application Supplement <br /> JOB ADDRESS:_23D E, C-H> Nl 1rSTlSW<+ y, PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION, (LGD) <br /> I thereby 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. a <br /> License#: � C Expiration Date'. ---- <br /> Date: fo 'Lj Contractor: F15 )4 DC L L L_J IJ6- <br /> Signature: . Title- <br /> Printed name: r V1 <br /> WORKERS' COMPENSATION DECLARATION <br /> I_hereby affirm under penalty of perjury one of the following declarations. (CHECK ALL WHAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure'for workers'camperisa[ion, as provided for b <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued, Y <br /> �[I have and will maintain workers' compehsation Insurance, as required by Section 3700 of the Labor Code, <br /> fof the performance of the work for which this permit is issued, MY workers' <br /> carrier and policy numbers are: a kers' compensation insurance <br /> Carrier. rn � Policy Number: 0 <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 became subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3704 of the Labor Code, ; shall <br /> forthwith comply wlth those provisions. <br /> Date: o Signature: <br /> Printed Name. Y)C/ �,S_ew <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 RUNDRED THOUSAND DOLLARS <br /> (5100,000,},1N ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES, ANp DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> C <br /> I' C (C-57 licensed authorized representaiive),hereby <br /> authorize <br /> to sign this San Joaquin County YYell Pennit Application on my behalf. I understand this awth0e=tion is valid for <br /> one(i)year and is Ilmited to the walk plan dated-on the front page of this a plication. <br /> RECEIVED TIME AH. 10. 9 : 39AM <br />