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06/28/.2005 TUE 14:21 FAX 0 002 <br /> PAG. U2/[1.3 <br /> 00: 2,J 71F(ib1.Fl43I1 <br /> Sim Joaquin County vironmentaI Health Department Unit IV Weil Permit Appimation�ut't�lernent <br /> JOB ADDRESS:_, PERMIT <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and <br /> �Professions Code and my license is in full force and ffect. �� <br /> License#:_� Expi oration Date: <br /> Date:_ —Contra tor. V v`'D <br /> Title' <br /> Signature: <br /> Printed name: <br /> C 1 i <br /> WORKF_RS' COMPENSATI DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _1 have and will maintain a certificate of consent to self-insure for worker:'compensation,as provided lot <br /> by Section 3700 of the Labor Code,for the performance of the work forwhich this permit is issued. <br /> ,_I have and will maintain workeri compensation insurance, as required <br /> wo kers' ation 3 00 of the nsurab or ceCode, <br /> for the performance of the work for which this Permit is issued. My <br /> carrier an policy nUmbe <br /> Carrier: l/ Pnlicy Number:1 <br /> I certify that in the pertamtanca Of the work for which this permit is issued, I shall not employ any person in <br /> any mannerso as to pccome subject to the workers compensation laws of California, and agree that if I <br /> should became subject to the workers'compensa inn provisions of Sec ton 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. 7 <br /> Date:_ Signature: <br /> printed Name: D Y <br /> EMPWARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL A D SHALL UBJECT <br /> AN <br /> AN EMPLOYERTO CRIMINAL PENALTIES AND CIVIL FINES uP 70 ONG HUNDRED THOUSAND DOLLARS <br /> (Stao,000.),IN ADDITION TO THE COST Or: COMPENSATION,INTEREST,ATTORNEY'S FEES,ANu DAMAGES AS <br /> PROVIDED FOR IN SL':cTION 370s OF THE LABOR CODE. <br /> /A/P/THORIZAy%T9IOONN FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> el (signori ra ofC 57 ' ® ed authoriz d ranreaentativeh <br /> hereby authorize Iprint norma) <br /> to sign this San Joaquin County fill Permit Aptillcatlon on my behalf. I undnrstand this authorization is vRIId int <br /> one(1)year and Is Ilrel ted to tho work pian dated on the front peg&of thin aliPlloation. <br /> 06/28/2005 TUE 15:37 tTX/RX NO 64241 002 <br />