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Y r <br /> -Son Joaquin Cguttty n ronmentai Hewlth DoParf+Went Unit IV W011 POrr»it <br /> A}�}711C11tlan Up�lsmar9 <br /> JO® #�r�3R5 o C PER3V�IT SRO' <br /> i <br /> ! <br /> LICENSED CONTRACTORS pECLARATION <br /> I hereby atfirm Chas i am izensed under the provisions of chapter 9 (commencing with Sec;,on 7000)of 06619r4 <br /> i 3 of#t) 5V51ne5R and Profeeslona Code and my license is in Bali force and effec'. <br /> Lk er se : . Expiration Date: <br /> f <br /> Date, / - C7 ontrector; <br /> Signature' __-- _--TItN: <br /> F <br /> i <br /> 1 r+rrnted narnc ! <br /> WORKERS' COMPENSATION DECLARATION E <br /> hereby affirm Under penalty of psr�urf ore of the following declarations' ( HECK ONE) <br /> I have: and will maintain a certifrate of consent to salt-Insure for woikers,compeneation, as provided'or <br /> by se,�'ion 37N of the Labor Cod% for the perfOrm�wca3 of the saark fot ivttich this permit is iaauad. <br /> -taste aria will r-naintaln workers'cornwnsavo-i insurance,as rrglilrea t,.-y Seca;on 3700 of the Labor Coec, <br /> far iiae pe iormarce or the work for which this permit is issuod, My wflrkars' c; mper`;$0b0n insuranc,45 <br /> j cadet and po4icy nurrioers Aeb; <br /> Carrier'. Ann'(&_ Palley Number: <br /> ! cortafy that;n the perfdrmance of the work for which this permit is issuoc% I shail not employ any perspn ire <br /> I <br /> any Manner as as TO became subject to 1110 w0fl(ei's'u mper-,satlon lave: of California, and agree that if I <br /> 5:"kould became subject tv ilia workevu'Go'�r msat`ZoAipni vection 3TAC of t�+e i abet Gala, i s +?.I <br /> tarthwilh comply with MOSO proviaions. <br /> � r <br /> Printed Marne: . <br /> ir3l,AANINGC FAILURE TO sEcur(E WORKERS'CgN1PENSATION COVERAGE IS>.ilNi.AWFUL,AND SMALL SU5JrzC f <br /> ' AN EMPLOYER TO CRRAINAL PE4ALT1E9 AND CIVIL F=INES UP TO ONE rHUNPREP TNOUSANb DOLLARS <br /> IN APD(TION TO THE COST OF COMPENSATION,IMrMST,A'f ORNEY'S FEES,ANIS CFAI�'..AGES A$ <br /> ! PROVIDED FOR IN SECTION 3704 OF TttF; LASCIR CODE. <br /> AUTHORIZATION FOR OTNl�R THAN C-57 SIGNING PERMIT (APPLICATION <br /> f, \k, r- c, v { CL o rA a n jSiflnsturs M_a7 I1rgne d nuthorixsd rePrs�o,ltmt f I: <br /> i <br /> to Sign thimi San JosquFirt County WAIL Parrnit Application 00 my ltahxir. 1 urwemtana.ills aVwxv lXllttoil i;Y�Fli4�Sir ! <br /> tlne(1)year and is limited to t"work Bien dated on that front page of this applicaboa. <br />