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09/,08/2004 08:33 FAX 9168792900 URS-SACRAMENTO-GO • E002/004 <br /> 01.' 0!2004 70:24 20446t13 j3 <br /> FIFTH FLOOR PAGE 03 <br /> San Joaquin Cou!Zil <br /> al Health DepaRment Unit P il 7 r$itRAPP <br /> lieation Supplement <br /> JOB ADDRESS: Cl e eQ <br /> LICENSED CONTRACTORS DECLARATION (LCD of Division <br /> I hereby affirm that I am licensed under the provisions a of Chap <br /> Ler 9 (commencing with Section 7000 <br /> 3 of the Business and Professions Cede and my license Is in full force a�effec / ✓ :04 4 '�-- <br /> !(l _rpiration Date: <br /> License;':�C` I �Ac) <br /> Date; Cont Cont actor: <br /> ✓ —_ Title. <br /> Signature' � � - <br /> Pflrit name'. <br /> WORKERS' COMPENSATION DECLARATION <br /> Perjury one of the following declarations: (CHECK ONE) <br /> I hereby affirm under penalty of sent to self-InsUYe for workers'rompensation, a provided for <br /> I have and will maintain a certificate of conlel <br /> erormancc of the work for wi l this permit is issued. <br /> by Section 37,30 of the Labor Code,for the pfas required by Section 3700 of the Labor Cade, <br /> t have and will maintain workers compensation insurance, <br /> for the performance <br /> the work for which this Permit is issued- My workers'compensation insurance <br /> carrier and po cy numbers are: / Z <br /> i ^ I N V Policy Number: W� <br /> 0y� ' t t an erson in <br /> Carrier: is issued, 1 shall not employ Y P <br /> ensation laws of California, and agree that if I <br /> I certify that in the performance of bjthe work for which this permit s ns of Section 3700 of the Labor Code, I shall <br /> I any manner s0 as to become subject t, the workers'col <br /> prop <br /> should became subject to the workers'comp p <br /> Forthwith comply with those prOvislons. <br /> D ` � Signature ,.t <br /> Date: <br /> I Printed Name: <br /> WARNING:FAIWRETOSECUREWORtCERS'COMPEN5ATIONCO'ONEHUvEFAGE DRED 'HOUL, <br /> AND SHALL SUBJECT <br /> AN EMPLOYER T4 CRIMINAL PENALTIES AND CIVIL p1NE5 UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED M TO 5E TI N 3706 OF TNEFLABDR COMPFN5ATION,INTEREST,ATTORNEY"S FEES,AND DAMAGES AS <br /> I AUTHORIZATION FOR Or�RTHAN C-57 SIGNING PERMIT APPLICATION <br /> (signature pfC-s7licensed authorized representativel, <br /> 11 hereby authorize(Print name) <br /> I to sign this San Joaquin County1Nell PermitApPlic2lion on my behalf. <br /> lundarswnd this quthoriYativn is veli °r <br /> I one(f) thated on the front pa9 <br /> e of this application. <br /> Year and is limited t0 e work plan d <br /> 8-29-02 <br />