Laserfiche WebLink
Jul 07 04 09L54a <br />07/07/2004 00:44 <br />916-- t'-9558 <br />20946,W,18 r'r I AGE STOCKTON `,% <br />P.1 <br />',>AGE 02/02 <br />San Josqum County Environmental <br />O �q� <br />JOB ADDRESS: � 1�) I I It' ` 4 p . PERMIT SR#,— <br />LICENSED CONTRACTORS DECLARATION <br />I hereby morin that 1 am licensed under the provisions of Chapter 9 (comm <br />3 of the Business and Professions Code and my license is in full force and <br />wORKERS, COMPENSATION DECLARATION <br />I hereby affinr+ Under penalty of perjury one of the following declarations' (CHECK ONE) <br />1 have and will maintain a certificate of eonatnt to seM Insure for workers' com lers:n+en, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this ix:rthlt Is issued. <br />I have and will maintain workers' compensation insurance, a: required by 5ecbon 3700 Of the Labor Cod( <br />for the performance of the work for which this permit is issued. My workers' Compensation msuranee <br />carrier and policy numbers re: <br />JJ <br />Carrier. (Crn{2r.Jy OPCrf�lj�"�'�olicyNumber: 11w �. J <br />1 certify that in the performance of the work for which this permit Is Issued. I shall not employ any person ii <br />arty man nor so as to became subject to the workers' Compensation laws of California. and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I sha I <br />forthwith comply with those roviaiona. <br />Expiration Date: �r /-15r�o Signature: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, AND SHALL SUBJEC T <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100.000.N IN AOOITWN TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES. AND DAMAGES AS <br />PROVIDED FOR IN SECTION 7709 OF THE LABOR CODE. <br />FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br />EM 29-02-0o1 <br />srtOM2 <br />