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7:36AM FROM <br /> 20i66L;Yu„ <br /> FIFTH*FLOL P. 1 <br /> PAGE 02 <br /> FILE COPY <br /> ntal Health Depytriment Unit N well P. it Applic0pn <br /> JOB Aa7DRLSs: c �-. <br /> +� ^ �� ^e ♦. - PERMIT <br /> DECLARATION j <br /> LICENSED CONTRACTORSL <br /> I hereby ah"'m that I am licensed under the provisions of Chapter 8ramme <br /> j 3 bf the Business and Professions Coda-and my license is in fill)force and effect, <br /> f hang with Section 7'000)of Division <br /> �� <br /> License#: 2 ,-- <br /> Dale: � > -Expiration llata; � <br /> --SA5�-� t' Z Contractor �— <br /> Signature: <br /> Printed nam®: <br /> vitle: l� <br /> f <br /> •.�, <br /> 77 <br /> WORKERS•COMPENSATION DEC <br /> LAWJiTION <br /> i heeby affirm under penalty of Perivry one of the I4abw no <br /> declarations: (CHECK ONE) <br /> _. i have and will maintain a eettif�cate of consent to Seliinsure for <br /> by Sect on 3790 of the Labof Code,for the performance of the Work for which this permit i6 issfor w�compensation,as Provided for <br /> ued. <br /> 1 have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performaince of the work for which this perrnit-is issued, <br /> carder and policy numbers are. Nly workers'cvn>pensation insurance <br /> i <br /> Carrier- <br /> M Lek-�licyNu,mber., l <br /> i certify that in the performance of the work for which this <br /> i any manner so as to become Suojm,3Ct to the workers.cempermit is issued,.1.shall not employ any person in <br /> should become aubiect to the workers,co pSions o f laws of California and, r <br /> ' <br /> r1with � w1 mpensationprovisionsofthat if I <br /> Section 3700 of the Labor Codi sha0 <br /> Provisions.�0. Signature: <br /> Printed Name: <br /> i WARNING;FAILURE TO SECURE WORKERS,COMPENSATION COVERAGE IS UNLAWFUL,AND SNAIL SUBJECT <br /> AN EMPLOYER TO CMMW#AL PENALTIES AND CIVIL FINES Up TO CiNrs NUNDRED;THOUSAND Ot>4.LAR3 <br /> IN ADMON TO THE COST OF COMPENSATION,IMREST,ATTOftNEY•S FEES,AND DLARS AS <br /> j PROVIDED FOR IN SECTION 37x6 OF THE LABOR COOF <br /> t AUTHORIZAT O' <br /> f' ir57 SIGNING PERMIT APPLICATION <br /> R l ^c (signature ofC-57 rlCensad authorised <br /> �^•�'>�•a•�•lw+w"rn.,n�7_ Ute{ m -ikmc,_._ ,�_ ^spresemadve). <br /> W sign this San Joaquin C*unty WWI Permit Application on W.� <br /> nmY befralf. I understand dmisetrdwriration l5 ealltl for <br /> �ancl is limited to the work plan dated an the front page of this application. <br /> 8-29-D2_I Mi_� <br />