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01/26/2006 TELT 15:30 FAX <br /> _ . 10002 <br /> San Joaquin Coun vilronmPritai Ith Dep a�ent Unit IV We- perm t P,pplioeti slppiemeni <br /> JOB ADDRESS:_.. It — PERMIT SR#: ©��— �2� <br /> LICENSED CONTRACTORS DECLARATION (Lei] <br /> I hereby affirm that I am licensed under Lha provisions of Chapter 9 (commencing with$action 7000)of Uivislon <br /> 3 of the Business and professions Code and my license is in full force a'nld. ffect. <br /> License,#: D t E�fxp(!'i�n nate: <br /> Date:. Contra <br /> signature• YTde" -. <br /> Printed name: I — <br /> WORMRS' COMPENSATI DECLARATION <br /> I herehy affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> Ihave and will maintain a certificate of consent Iv self-insure for workers' compensation, as provided for <br /> by Section 3700 ofthe Labor Code, fur the performance of the work for which this permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Ser;tion 3700 of Bic Labor Code, <br /> fur the periomrance of the work for which this permitis issued. My workers'compenfs}ation insurancecarie,an pblicY ntm� are: � <br /> Carrier. - Policy Number:�/� V <br /> 1 certify that in the performance of the work for which this permit is issued. I shall not employ any person in <br /> any manner so asto become subject to the workers' compensation laws of California,and agree that if I <br /> should become ut>ed to the workers' compensa on provisions of Section 3700 of the Labor Code, I shall <br /> forth ith�Ciomp) vvitlt those promsions. 7 <br /> Date: N� ` Signature: l <br /> Printed Name'• <br /> ;WARNING FAfLURE TO SLiCURE WORKERS'COMPENSATION COVERAGE IS UNLAWFU A D SHALLSUDJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND clVIL FINNS UP TO ONE HUNDRED THOUSAND DOLLAR <br /> (Sl 00,00D.),IN ADDITION TO THE COST OF COMPENSATION.INTEREST,ATTORNEY'S FEES,ANn W AGES AS <br /> PROVIDED.FOR IN SECTION 3106 OF THE LABOR 4-,ODE- <br /> �3Tki .PIZATlt7VJ FOR THAN C-57 SIGNING PERMIT APPLICATION <br /> I hereby a;uthvrim(print name)^ ���.�/y�' I���g,�atun� rcensnq a 4horized rap2sentative), <br /> V-iu.,thr> all Permit Aimilcatinn ort my behal!, t understand f•,ie auth:%r4.:eUen is va![d for <br /> one(t)year Aud rs limned io the wei K pian d;lted 97 the froea page of thr3 zP0Ict9t10li. <br />