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sat,Joaquin County Emrtronmental Hti'ittt Dppartmant UWAt 11t',wen PBmrit ApplicationSUlarnant <br /> w '. ' '.Tfa PERMT SRO• <br /> JdBADDRESS: .3DD Ea a: <br /> - a <br /> LICENSED CC)'NTRACTORS DECLARAT10M LCD <br /> I nereby affirm that 1 am licensed under the provisions of chapter 9(c6mmencing with Section 7000)of Division <br /> 3 of iMe Bullness and Pratesstans Code artd my ncense is in fust force and e4ied. <br /> Expiration Date: <br /> �—14-�,Gontiedor �F: SG � <br /> Date:, -_ <br /> Slgnatufs: <br /> Peiretnd name: ' <br /> WORKERS'66116PlEIVSA11716 1 DE&ARA'I•ION <br /> I hereby emrrn under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I ba4e and wili mgintain a cettifl=4 of rionserit to selMnsure for workers'mrnpentation.as provided for <br /> tile'performance W the work for which this permit is issuad. <br /> by Section 3700 of"labor Cade,for <br /> ;ka i <br /> ✓I have and will maintain worja-ml arppensation insurance,as reRuired by Seof on 3700 of the Labor Code, <br /> topedormarwe of tate work for which this'permit is issued. My warkere comPenaatian <br /> r'the insuranCa <br /> carrier and policy numbefs are: <br /> f��94tP <br /> Carrier. Policy[+tumtlsr.. -- <br /> shall not em l an an In <br /> I car'ldy thet in the performance Ofiha work fpr which this permit is issurd, P�l Y <br /> any rriannerso IS to Wcorne subject to lite workers cotnper%8800n taws af Caiirorairs,and agree tttat If I <br /> e soli to <br /> the worker's'clompensation prpvisrnns,af Section 3700 of the Labor Code.I shall <br /> d beco'trt <br /> sh6u1 � <br /> forthwith asmRY <br /> i with those gn:Ms4ons. <br /> gcpTratlon pate•.��Slgnatare:, I��� <br /> Printed Manic: <br /> WARNING:FAILURE TO SCCURE WORKEILB'COMPMSASION COVSRAGE i0 UNLAMIF{JL,Jlttb S7J6lFC r <br /> AN EIIIPLOYER TO CRiMMIAL PErrtALTIES'FAND CML FINIS LIP TO ONE HUNDRED THOUSMIb DOLLARS <br /> tOAWj } <br /> (s1t16,0B0.1,IN ADOMON TO THE COST OF COMPENSATION,INTEREST,ATTORNEW6 FEES,AND O1�tttAGES 1aES <br /> pROVjf*a l:GR IN SEGTTON 9766 OF THE LAaOR CODE, <br /> AUTHORIZATION FOR QT THAN C-57 SIGNING pERMIT APPLICATION � <br /> {{ <br /> is 7liosnied authortmd repr=$ritstivr},. <br /> i tJut'1. .`s <br /> E r4rsby autApHzs{print name} <br /> IP1 ; <br /> to sign this San,ladpuln t:nunty Wst1 penrrit.Awileation on my ollalfl i understand this:utlloriLaLl4n la valid for <br /> E' lication, <br /> 6%o(t)year and Is rlmftd CO the W*rkP"dim <br /> QR tate frpllt page at{1116 application, <br /> 6.$9-021>illl . <br /> l3HD�-0'2�D: <br /> Ed Wd6e:TO L0W 6T 'Jew £8861iB£f} 662 C11 t �OHd s isF I euy o Jaz puna��j l IO�ij <br /> i <br /> 1 <br /> y <br /> .., 1 <br />