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Naw, San Joaquin County Environmental Health Department Unit IV Wed Permit Application Supplemental JOB ADDRESS: 549 1 t' S r BArdm CA PERMIT SR LICENSED CONTRACTORS DECLARATION (LCD) 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#: `2 t o 0`1 a I Exp Date: 02- 3 ('- l Date: () 7- Z:$-R 9 Contractor: Lwpn w#*t 19.,it,U A!r,- CO IW AAN Signature: _ �l/ r.>! Title: p"ymer Print Name: Co,UClAn;r E_ tAtgot)MIa" WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perl'ury one of the following declarations: (check one) I 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_ ,X I 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: STM FRWD Policy Number. 6!J q 1 d n 2.07.T 3_t I certify that in the performance 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 law of California, and agree that if I should become subject to workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Exp. Date: l D" 200 4 Signaturo: Print Name: CeyctArr, id tnr4rgQkQ& WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVMME 14 UNLAWFUL,AND SHALL SUtt.IECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO$100AN,IN ADOITION TO THE COST OF COMPENSATION,IWEREST, ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 5700 OF THE LABOR CODE. AUTHORJZATI(?N FOR OT M THAN C-57 SIGNING PERMIT APPLICATION 4 (signature of C-57 licensed authorized representative), hereby authorize(print name) X111 N Q--tiQE EN E ,to sign this San Joaquin county Weil Permit Application on my behaK 1 understand this authorization Is valid for one year and is limited to the work plan dated as dw fromt page of"a sppiication. srteraina EM2"i 1116101 N1F44?EOMI A"