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LAX)' <br /> �r <br /> i <br /> Ban Joaqutn Zounty Environmenfavl lifrtlth.Drt <br /> epament Wilt 1V Wel!Prermtt Application SuPploment <br /> D5!S-3ly <br /> 2 Trdteg PE;RHiIT SRef:, <br /> .JOB ADDRESS: 2. (o <br /> i <br /> i <br /> LICENSED CONTRACTORS DECLARATION {L-CD <br /> I hereby firm thi3t I am licensed under the prouisions of Chapter s(cgmmenring with Seaton TpOt})of Division <br /> 3 at"Business and Plydesvlors Cade endltiiy li:ense is in full force and afifati'i. <br /> trcensslf: �13d 6-s Expiration Date: <br /> Bate: I -( ] Contractor. '' Sty �Q t W Signature. �L Yule: <br /> •=4 <br /> Printed name: <br /> lye" <br /> WORKERV COINAPENSAT M DECLARATION <br /> I Hereby afnrrn under penalty of perjury one of the fbIlowing declarations: (CHECK ONE) <br /> _I have and will maintain a cerlifica*of consent to selMnsure for workers'compensation.as provided for <br /> by►Section 3700 of the Labor Code;for iiia Aetforrnance eT lire work for which this permit is issued. <br /> urred seettan MID of the Labor Code, <br /> ►/I have and VXII maintain workers'cgmpensafion frsumnee, req 'warks'compr}nsatien insurance <br /> for the performance of the work for wbich'this perrnft is issued'My <br /> carrier and policy numbers erre: <br /> Policy Number. ,r --- <br /> 1 certify that in the perfomtalrc:e bf the work'fpr�whtctr this permit is issued,[sh44- <br /> a11 not employ any peravn to t <br /> any mannarso as to become subject to tttie ysrprkera'cnmp6ltsetion taws of Ca1PFornis,and agree that if I <br /> of the Labor Code,t shad <br /> shoWd beWlne subject to#*workers'cOnipenseUon proviMons of Section 3700 <br /> forWmth comply with 1how provislons.. /�--- <br /> i <br /> Exp1mven Date t3lgnlltar <br /> Prinud Morass' t Gl t 5[ <br /> OLLARS <br /> WARNING:FmLURE TO SECUitE WORKEF'S,.iamp,1"SATIOFI Cp1f�RIcGE IS U11u4WF1lL,ANd SHALL SLtBJECT i <br /> AN EYVIPLOYER TO CRIMiINAL PENALTIES AMC t:ML.FINES Up TO ONE HUNpRED THOLI"MD D <br /> IS190,M0.1,IN ADMIION To THE COST OF COMPE NSAT10N,INTEREST,ATTORI+11_Y'S FEE6,AND DAMAGES 1�3 <br /> PROVIDED FOR IN SEGTION 3706 OF TM LABOR CODE. <br /> w <br /> AUTHORIZATION FOR QTHER THAN C47 SIM411MG PERMIT APPLICATION�a-V V !=7a�tutreby auftorizrr(print name) <br /> to 41gn this San Joaquin County W"pa"nit.'Appllettlon on nW bobaff. i upd0rstand thts authoriz Ireton[a Valid for <br /> 01►@(1)year and IS Itml6sd to the Work Plan d ipo <br /> on rise front 1" t <br /> of 8rle application. <br /> j <br /> S.7g.p211r11 <br /> 62TJ09 - ° <br /> �d wd6eIIO ZOOZ 6I 'AFW f3f3G Bre 602 'Otd SK.DHd sTSA1VUV osaz punoaq W(71~iJ <br /> I S <br />