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San Joaqui my EnvirvnentW Health 3ervi4u; Uni!M ell Perml .AppJJes lon supple,""" <br /> Joe ADDRESS; zZS V--L4—,9gGC c PER-Mrr' SR#: <br /> ©0 3� 7 <br /> UCENSED CONTRACTORS DECU RATS NLt...CQ <br /> I hereby aft n thet i am ticansed under the provisions of Chapter 9 (camrner»n ilii Section 7000)of DWv sw <br /> 3 of the Business and PrWestsicns Code and my 1k=**is;n W force an <br /> Ihense#' U 610 L) �/.... _F-Virailon Date/ ©L <br /> Date: 0\ Contl'actor, <br /> Slgnatuiw: Tithe: (�` JAI2J <br /> Primed naive: rn a. 6e, <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under per;alty of perjury ane of the fcilawft declarations., (CHECK ALL THAT'APPLY) <br /> I have and will maintain p siei'tiftite of consent to ae;f-+naure for workers`+i�mperssa#l0d,as Provided far.hy <br /> Section 3700 of the Laker Cade,for the pederma nce of ille work far whim this permit is issued. _ <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 eche Labor Code, <br /> for the performanea of the work for which this permit is issued, My warkers' compensation irarans* <br /> carrier and policy numbers are: � .�J,, r� <br /> Carrier:— u LZ � 9n LC— _Policy hlurnber: <br /> I certify that in the perfomwce of the Work for which this permit is Issued, I shall riot employ any person in <br /> any manner so as to becorna subject in the w*tes'cnmpensaWn tern's of CW t mia,and agree that if I <br /> shnuid b=mse subject to the workers'campensatim provisions of Section 3700 of the Latter Cade„I shall <br /> forthwittr compiy with those provisions. <br /> Date: Signatur*: <br /> printed Name: <br /> WAMN6:FAILURE TO SECURE WOfOMRS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUMIJECT <br /> AN EMPLOYER TO CRHAINAL PENALMM AND CML.RUES Ur TO ONE MUNDRfED TFSOUSANO DOLLARS <br /> ($100,0130.1,IN ADD1TlOMi To THE COSTOF COMPERSATION,IKTERES-T,ATTORNErS FEES.AND aDAMAM AS <br /> Pm v mm FOR IN OF-C 3ON 3705 OF'Di1,°LMDR=E.. <br /> a_,VL4 Lt { 1 C.•57.11cansed authsardmed repneswrtathre).hft*bY <br /> authame L&iI t f l 0- i't l :1'LCe ✓7 , <br /> to silp ibis ran Josquin County W"Permit Appil an an my twhaif. 1 understand ihts AudwriuftV b V10d for <br /> one(1)year and 3s Olmsted to go work plan stated sen the fm Nit page of this OWC211140. ' <br /> s-17-=011111 <br /> I <br />