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0-1 291-"2�10 I L 9 7J^ 7417, .11--10L1NARL1 DF'1LLI111-,.,j F-`GE <br /> (11 _9 A,'fli Mid) 13:0 I-AN 92o 60-14?20 JN(' lVoodward TwiHin Z003 <br /> 15: 21 20446e3d3--j F--F'I'H ELDER PurE- 0-1 <br /> san Joaquin County Environmental Health Services,Unit IV Wall Parmit Application Supplement <br /> 1108 ADDRESS' I(POMarc ) Ici*r) PERMIT SR#.' <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> ~isreby affirm that I am licensed under the provisions of Chapar 9(commencing with Section 7000)of Divisicr <br /> —,,to Stj <br /> ,JnP_q.s and Professions 'ode ana my i cenAa is In fufl force and effect. <br /> .Jcense Fixiair2tion. D2te 7 0 <br /> 77 <br /> ontr—actor: LL <br /> Signature: <br /> Title: <br /> Printed n2ma: <br /> WORKERS' COMPENSATION DECLARATION <br /> -ef-eby aff rm under pAnatly of perjury are of the fullowing declarations: (CHECK ALL THAT APPLY) <br /> I have and will'na0tairi a r-,erhficata Of C015ent to salf-insure for worKars' compensation, as provided for tjy <br /> See.ion 3700 0f the Labor Coc4e, for the oerformanr;ek of the work tur which this porrni' is irnun d <br /> I hAvi- and will maintain workers'compensation insurance, as required by Section 371iG of the Labor Cadu, <br /> for ttie porformarice nT the work Cor which this pormit is issued. My workers' compunhatoan iriburance <br /> Larrie, nral policy numbers are, <br /> Carrier Policy Number: <br /> I r-Folify that in the parformaricu of the work for which this permit ib issued, I shall not u,mploy any persnrr;n <br /> any manner au w� Lu L-muum"- �ublzzut Lu the work.rb'aompensation laws of Catifamia and agree,that i4 i <br /> should become subject to the wQrl<e-r,;' ccmpensaton provisions of Section 371710 mf fhp Labor Code, I shill <br /> forthwith comply with those <br /> .—Signature: .— <br /> Printed Marne: <br /> WARNING; FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAwrUL,AND*HALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> M100,000.1,IN A=TION TO THE COST OF COMPENSATiON, INTEREST, ATT-ORNEY'S FEES, ANO rIAMAGIts As <br /> PRC)vIDEID FDR IN SECTION 3705 OF THE LABOR CQUE. <br /> _(sfUnwture otr--57 liceriseil authorized represerttatllv-s), <br /> 'iereby authorize(print name) X, <br /> to sign this San Joaquin County WL-11 Permit Application on my behalf. I und4ristand this autt-orzat'on is valid for <br /> yadr and is limited to the work plan dated un thr front page of this application. <br />