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2002 <br /> San .ioaquIn County Envlronrnen-76-1020 1 n S,errl�da, Ui�It_1V E sIiDDIetnent <br /> JOB ADDRESS: o�Jr © � PERMIT. :sRa! <br /> LICENSED CONTRACTORS DECLARATJON (RCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 0 (comrnencing with section 7000)of Division <br /> 3 of the Busineesrs}and Pr <br /> o <br /> fessions Code and my license is in full force and effect. <br /> License <br /> d�#II: /UID/U'7' Expiration Date: <br /> ontra <br /> Date: <br /> �-t <br /> Signature, f� + / Title <br /> ctor: • �� <br /> Printed name. ! f �- . <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury enc of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> ~Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> V/I have and will maintain workers' cornpensatiOn insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> � �� Policy Number. <br /> Carrier' ^^" <br /> I certify that in the performance of the work for which this permit is issued, 1 stall not employ any person to <br /> any manner so as La became subject to the workers' compensation lavers of California, and agree that if 1 <br /> should become subject to the workers' compensation provisions of Srtibn 3700 of the Lobar Cade, L shall <br /> forthwit cam ly with those provisions. <br /> Ali' <br /> II,,L <br /> Date: Signature: 1 . <br /> Printed Name:�,4- <br /> WARNING: FAILURE TO SECURE WORKERS' COMP F-NSA'f1ON COVERAGE IS UNLAWFUL,AND SHALL_SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> A } E-MF1).}, )>.l ADDITION NA THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMACES AS <br /> PROVADED FOR IN SECTION 3746 4F THE LABOR CODE. <br /> I, (IC,-57 'termed authorised repro6vntafive), hereby <br /> authorize <br /> to sign this Sa .}onquin Coutitty Well P it Application on my behalf. I und©rstand this autnas-►ration 115 valid fov <br /> oma(1) <br /> year and is IimiteC to thework pian dated on the front pa a of this application. _- <br /> 04/13/2004 TUE 14:44 [TX/RX NO 96681 R002 <br />