Laserfiche WebLink
San Joaquin County EnvironmentN Ith ServlcM,U It 1V Wall Permit Application SuppMment <br /> I! JOB ADDRESS: �� � PERMIT SR#: D Z�llO ro <br /> 1 LICENSED CONTRACTORS DECLARATION <br /> I <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 8(commencing with Section 7000)of Division <br /> 3 of the Busirn-e�sss and Professions Code and my license is in full force and effect. <br /> i License tt: /tZ <br /> Expiration Date: 00 <br /> Date: ntractor: <br /> r � //// <br /> Slpnitlure: Tltle: y'��Lr�tty <br /> Printed nems:�oc�U �� . f/( Iriryt i <br /> WORKERS' COMPENSATFON DECLARATION <br /> I noreby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 1 have and win 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 /> i <br /> I _I have and will maintain workers'oompensation 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 /> Carrier:� � FaG� Policy Number. lyk&51445� 5 <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person In <br /> any manner 80 as to become subject to the workers'compensation laws of California, and agree that if 1 <br /> should become Subject to the workers'compensation provisions of Section 3700 of the Labor Code, 1 shall <br /> forthwith comply with Diose provisions. <br /> Date- Signature: <br /> PrIII Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> I PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1' '7 Frwrsed authorized representative),hereby <br /> aufharit:a 1Q I iPA) EN V I IQQ ) /An&--PJ Til! _, k+. <br /> to sign this Sen Joaquin Coungr Well Permit Applloatlon on my behalf. 1 understand this authorisation Is vend for <br /> one 01ear and IS limited 10 the work Plan dated on the front eM of Oft application. <br />