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10/04/99 10:47 FAX 17]01 JOB ADDRESS:o` cro i 3 aacdo: e PERMIT SR#: V aQ - LICENSED CON;'�ACTORS DECLARATION ( CD I hereby affirm that i am licensed under the provisions of Chapter 9(commencing with Section 7000 of Division 3 of the Business and Professions Code)and my license is In full force and effect. License 0: Expiration Date: Date:_ Co ctor. pia , ,rY Signoturo' l Title: l� /it 4&AAA, V 1v Printed name• t&ru WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations; (CHECK ALL THAT APPLY) 1 have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for by /Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. �/ 1 . have and will maintain workers'Compensation insurance,as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers'compensation insurance carrier and policy numbers are: Carrier. l7ntiC M CaA Policy Number: wc--Edqfff�q-O5 I certify that in the porformance of the work for which this permit is issued, i shall not employ any person in any manner so as to become subject to the workers'compensation laws of California, and agree that if 1 should become Subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shalt forthwith comply with those provisions. Date: L4 1 "l Signature: t% Printed Name: WARNING:FAILURI"TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, NDSHALLSUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000.).IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTIQ 706 OF THE LA13OR CODE. I, (C T license holdor),horoby V, +authorize 4 of ! ulting).to.sign thin San Joaquin County Woli Pormit Application on my bohalf. I undoratcrid thins authorization In valid for one(1)year and is limited to the work plan dated on the front pago of thus application.