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Jul. lL ZUUh 1 :9tlYM Ar -nCed GeOEnv lfonmenIai No. 1405 P. 2/3 <br /> llp,lie' <br /> San Joaquin County Environmental Health Department Unit IV Wall Permit Application Supplement <br /> JOB ADDRESS: V03 C4v01t-,1 CJva PERMIT SR#: o��l�zo5 <br /> 61vo <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> 1 hereby affirm that I am licensed under ft provisions of Chaplei 9(commencmg with Section 7000)Of Diwision <br /> 3 of the f3usin and Professions Code and my license is in full force and effect. <br /> License : S-u 0, ) Expiration <br /> L. 1C) l 3 l eV <br /> Date: D Contractor.� /"— <br /> Signature:_ -Tine- <br /> Printad name- <br /> WORKER 'COMPENSATION DECLARATION <br /> I hereby aMrm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of torten to self-insure for workers'compensation,as provided for <br /> Zby Section 3700 of the Labor Code,for the performance Of the work for which this permit is issued, <br /> have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code. <br /> the performance of the work for which this permit is issued. My workers'cDmWisaton insurance <br /> i <br /> carrier and policy numbers are: <br /> Camp Policy Number <br /> I certify that in the perform ice of the work for which this permit is issued.I shall riot employ any person in <br /> any manner so as to become subject to the workers'ccimpensation laws of California,and agree that 9'1 <br /> should become subject to the workefs'compensation provisions of Section 3700 of the Labor Cade,I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: SignaWre- <br /> Printed Name: L't CL <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML rINES UP TO ONE HUNDRED THOUSAND 1301 TARS <br /> 4100.0003-IN ADDIYION TO THE COST OF COMPENSATION,INTERES t,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR M SECTION 3706 OF THE LABOR CODE_ <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. moi- Isigrvture otC-67 licensed authorized reps ete-matival, <br /> hembyauMorQe(pd name)._ E <br /> to sign this San Joaquin County Well Pemdt Application on my behalf. adtirstand MIs authonzaten Is valid I <br /> one(1)year and is limited to the work plan dated On the front page of this application. <br /> IF29-021 MI <br /> EM 3407-001 <br /> 622/01 <br />