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Sar~Jaaquln County Environmental Health Spt'vless,Unit ICY W911 >P.urmit Application Supplement <br /> JOB AUC tESS;3 r� PERMIT 3R#: DD 260 <br /> LICENSED CONTRACTORS DECLARATION (LCO <br /> I herehy affirm that I am licensed under tho provisidris-of_Chapter 9(commoncing with Section 7000)of Division <br /> 3 or the Business and ProfessionS God®and my license ie!ri tali force and effect. <br /> Licanss#• 7 7 Expiration [late. <br /> Elate, 6e-l-6 2 N A f Contractor: <br /> Signature <br /> Printed name: i �'i' �0 d�4r47�1?3 <br /> WORKERS*COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of ttie hollowing declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for worlters'cornPu tsatlan,ars provided far by <br /> Section 3700 of the Labor Lode,for the perfmmRnre of the work for which this permit is 1sumed. <br /> ave and will maintain workers`compensation required by Section 3700 of ute Labor Code, <br /> for the pertarmance of the work for which this pemdt is iaisued. My workers'componsanein insurance <br /> carver and poilcy numbers are: <br /> Carriaw: '� 0 <br /> Polley Number: ✓yt/�$ 98�/c °Z 60 <br /> I clrtify that in the performance of the work for which this parrnit is issued,I shalt not omploy any Person in <br /> any manner so as to become subiact to the workers'cornpensatlon IaWn of California, and agree that it I <br /> should become subject to the workers'comnan cation provisions of Section 3700 of the Labor Code, I shflll <br /> forthwith comply with those provisions. <br /> pate: 0IV-02-0 1 .�.. "nature: <br /> Printed Name:, 4+IF 'r' <br /> WARNING:FAILURE TO St CURE WORKERS`COMPENSATION GOVERAGE IS UNLAWFUL,ANO SHALL SUBJECT <br /> AN EMPLOYER TO ICFUMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> t2gt0VIDED FIN OR N ADDITION <br /> O HE Q �iFCOCCiMPEAT ON-INTEREST,ATTORNEY'S FFFS,ANI]MAMAGES A5 <br /> P <br /> c hl rrl+ _(C451 licensed muthorimd Fvpmsantmive),hemby <br /> to sign this San Joaquin County well Porrnit Appticatlon on my behetf. I undwstand thio authorization is valid for <br /> one(9)year and is limited to the work piem'luted on the front POGO Of this aPP1102tior" <br />