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3-11-205 9:40AM FROM F 2 <br /> t can.ioaquinCountyErtvlronntnnenftisalth. em:UnhIVVife11PermitAppllCation:SNpplemat <br /> JOB ADDRESS: :N3e keen „e L ' PERMIT SR#:� <br /> LICENSED COtH RACTOf22S OECl.A.CRATION (LCO) <br /> ' <br /> thereby affhrn that i am licensed under tite provisions o Chapter 9(commencing with Section 7000)of f7Wieim <br /> 3 of the Business and Professions Code and my license is in:full-ferne and offea <br /> .,�.Llcetise u,��11 �_. ..,�Expfo.Ition Date:.:....^�r,�1�..L 1 �j <br /> Date: <br /> Signature: r� �, r Title I <br /> Printed name_e: <br /> W0RKI!RS' C,0UPEN8A1,1DN DECLARATION , <br /> I hereby affirm under penalty of perjury one of the toll declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to w*insure for workers'compensation.as,provided for by <br /> 1 ..._..Sact i 3700 of the Labor Coda,for the performanc a of the work for which this permit i8issued, <br /> i have and-wilt maintain workers'compensation Insurance,as required by section 3700 of the Law C440, <br /> j for the performance of the work fur which this permi is issued. Arty workers'compensation ItrsavaMCB <br /> oanier and policy numbers are: <br /> Carrier., � P k Nidmber.G` e _. _ <br /> _I cortiflr that in the performenoe of the wor'it for whiM this permit is issued, I shail not employ any person in <br /> any manner se as to become subject to the work compensahan laws of California,and agree thTl e I <br /> should became subject to the workets'iimpensawn provisions C Section 3700 of the LaborCode, I shall <br /> forthWlth Comply with those provisions. <br /> Ifata: <br /> Printed No /-''' <br /> {l ma Y .d 7 5 t e1 RT <br /> — i <br /> WARNING:FAtLJRE TO SECUPEWORKERS'COMPEWWUN COVERAGE IS UNLAWFUL,AfdE;HAL%.SUBS)&CT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FI UP TO'DNE HUNOREO THOUSMdO DOLLARS {4 <br /> (3100,000,),IN ADDITION TO THE COST OF COMPENBATt N,INTEREST,ATTORNEY'S FEE&ANO DAMAGES AS <br /> PRWQ9DFORR W SECTION 3708 OF THE.LABOR CODE <br /> 1,, it /( <br />