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3 � .. w <br /> San Jaaqui my Envire0nentaJlealth 3mN!(= Unit fV WJ Penni .AppifesMon' suppiament <br /> JOB ADDRESS: Sym /V• Keg C PEMUT SIM. <br /> LICENSED CONTRACTORS'DECUkRATIONLt cad <br /> I hereby affirm that I am liC rt4ed under the provislans of Chapter 9 (co rtvn Sectio 70130)of Division <br /> 3 of the 8usinese and Profession:1� <br /> pda and my ticerraa Is in Ufa�a effect. <br /> t ,se#: _ D , Expiration Dat <br /> gate: cantYaciar. <br /> WPntad name: I! I l Q• r� <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the totlewNtg declarations- .(CttECK ALL THAT APIPL In <br /> I have and will maintain a certlHt:ate of consent to self-insure for worker:`=mPerzatl'on,as provided Forby <br /> Section 3700 of the Labor catle,for the performance of the work for whicM this permit is issued. . <br /> I have and wilt maintain workors'compensation insurance,as required by section 3700 ethe Labor Code, <br /> for the performance of the work for which this permit is issued. My markers'compensation insuemce <br /> carrier and policy numbers are: <br /> Carder. `� Roiiry Nu>rtrbar 't� O <br /> I cartlfy that in the performance of the work for width this permit is issued, I shall not ernpi+oy any prison in <br /> any manner so as to bwrne subject to tate workets'compensation laws Of CalifbrnW and agree that it I <br /> should become subject to the workers'compensation provisions of Sermon 3700 of the Labor C46k1 shell <br /> forthwith comply with those provisions. <br /> Date: Sig nates• <br /> Printed Nance: <br /> WAMONG.FAULURE TO SECURE WOMBS'COMPENSAT10"COVERAGE 13 UNLAWFUL,Atte SMLL.Sim <br /> AN EIAPLOYER TO CPJIAI14AL PENALTIES AND CIVIL FINES UP M ONE HUNDRED TH4DWAND DOLLARS <br /> (XI 00,000.1,IN ADIXTION TO THE COSTOF COMPENSMON,1td VREST,A7 MRNEY'S Ii E$,AND DAMMAGO AS <br /> .FltCV03ED FOR IN SECTION 2708 OF"fHL°WOR BODE. <br /> i C57 9cenaed mAharbmd n:prrrarrtatIVOL tw*bY <br /> L . ! d I a n d va f <br /> i <br /> to sign this San Joaquin County WOO I?ermit Apple tori;an my behalf. f understand this AuduJrUsS M'r Is Wild tier <br /> an■(t)year and is atnIted to the work plan dated On the ftnt pwo of d is appllaaliOrr, <br /> S-!7.7f1g0 l Ail <br />