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0 0 <br /> San J*&Wm County Envinmim"Health Deprhaent unit IVParnnit Application+fit <br /> .itis ADDREss: 13-731 A)ot# gia Le-Y gh �PumT Sw. <br /> LICENSED CONTRACTORS DECLARATION L( CD} <br /> I hereby affirm dig 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Busxmw and Professtons Code and my license is in M face and effect <br /> License al': gOas"3H Expiration Date_ (a/2>I(� <br /> Date- cpnaactor �5Z �h Lt i <br /> Signal ne; TRb• V1 <br /> Prhrtad name: kc <br /> •YORKERS'COMPENSATION DECLARATION <br /> 1 hereby affinr under penally of perjury one of the fotowing declaration: (CHECK ONE) <br /> _1 have and wit maintain a certificate of consent to salf-insane for woduers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit s issued. <br /> _>�q have and wilrnaintain wakens'no pensation insurance.as required by Section 3700 of the labor Code, <br /> for the performance of the work for which this permits issued My workers'mnpemsation insurance <br /> camber and policy numbers are: 1 <br /> Carrier PofoyUmber. -7 � 3 �rJJ3� —01P <br /> 13 <br /> I certify that n the pwkxmmamce of the work for which tis permit is issued,l shat not employ any person in <br /> any manner so as to become subject to the workers compensation laws of CaUbmia,and agree that N I <br /> should become subject to the workers' provisions d Sectio 3700 of time labor Code.1 alta• <br /> fortnvrtn comply we]torose prwsions. <br /> Expiallon Date: 1 Q11 :1 <br /> Prhhtad Nine: <br /> WARIwtG:FAMAIRE TO SECURE WORIERS00102OMTM COVERAGE IS UWAVIFUL Mil SHALL SUBJECT <br /> AN EMPLOYER TO CRi/ML PENALTIES AND CIV•_FINES UP TO ONE H tINDRID TItOUSAIO DOLLARS <br /> (ff3tA03.),IN ADORM TO THE COST OF COW-ENSAMK INTEREST.ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR M SECTION 37tt OF THE LABOR CODE <br /> A TION FOR OTHER THAN C-87 SIGNING PERMIT APPLICATION <br /> ovCST Rotlrea autnmtaed rwpre , <br /> hereby auttarioe(Pry mane) <br /> to sign this Sen Joaquin Carry Well Pang Application on nay behalf. 1 undwsdrd this aawftmOm+Is vatd for <br /> arc(t)yearad is tabled lotoe work Pian dared on On front page Of""aupptntlon. <br /> 3-79-02 10 <br /> EHD 29-02-WI <br /> 6/22Aa <br />