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j - Sin aeaquin Ceun"Z..vimr Qrt71 Ysai±h zerv1 nit t'J Afa9h?9mit- cllea !or. 3u cdanre. <br /> t o E��f u�ooc� <br /> JOEADDRZ-SS:CC ,.Jy= <br /> L.:CEN'SED CCNT?,J=C-G I3 ice:s i'a a'i 3 7� <br /> 1 ^ezov 3"Tm 'Shat I em li=ned under the pmVisicne of Chapter 5 (ccrnmer�rg wig;jecdcn 7CCC)of Division; <br /> 3 or',to Susiress and Professions Code anC ry flcanse is ',n full force and affoe- - <br /> License iJ Expiration Cele: <br /> nate: ,Q; Conlr-ac:cr. Y 'flt. <br /> I ff I <br /> 5}Snatura: � r ( Trife: W n JJ maw <br /> V <br /> Printed name: .1,4 ex, <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers compensation, as provided for by <br /> ��Sectlen 3700 of the Labor Code, for tha performance of the work for which this permit Is Lssuad. <br /> V t have and wdl maintain workers'compensadon Insurance, aa required by Section 3700 of the Labor Cade, <br /> for the performance of the work for which Ehis permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: ,�/ ,, <br /> Carrier:�,�ay� 1 'rPolicy Number: LN t-+ q-/s-b <br /> _I certify that in the performance of the work for which this permit is issued, I shell not employ any person in <br /> any manner so as to become subjeat to the workers'compensation laws of California, and agree that if I <br /> should become subject to tha workers'compensation provisions of Section 3700 of the Labor Code, I$hall <br /> forthwith comply with those provisions. <br /> Date: (���I Signature: <br /> r Printed Name: 1i4 2�ir(JJr-tom <br /> WARNING: FAILURE TO SECURE WORKERS'CCMPENSATION COVERAGE t3 UNLAWFUL,AND SHALL SUBJECT i <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (3100,0gg.),IN ADDITION TO THE COST OF COMPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED <br /> /FOR IN SECTION 317(18 O/F,T,fMELABOR CODE, <br /> n <br /> 11,_ / r / ` �1 K1��L C( C /Z� (C57 11"nand authorized rapreeeritaWe).hereby . <br /> It <br /> to sign thia San Joaquin County Welt Parnllt Appiicadon on my behalf. I undersand this authorization is Vatkt for <br /> C one(1)year and is limited to the work plan.dead on the front pzWv of this mppttcation <br /> S-17-2400 I MI <br />