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01/26/2006 THU 15:30 FAX QJ 002 <br /> an Jnaquin Gor,rrr viranmrntal Ith DeparllnPnt Un(t Weil Permit Applic,2/G/ ke <br /> un Suppment <br /> 7 i�IwRMIT SR#: ©" +��0 <br /> JOB ADDRESS:_ I I <br /> LICENSED CONTRACTORS DECLARATION UL .P <br /> thereby affirm that(am licensed under ilia provisions of Chapter 9 (commend rig with Section 7000) of Uivislon <br /> 3 of the Business and Pre4'essions Code and my((cense is in full force and. $act: ((�� <br /> 0y" E�prration Cate: 00 <br /> Date: Contra or, 11/iv1 <br /> Ttrye' - <br /> -Printed name: V � ' <br /> WORKERS' COMPEN5ATI� DECLARATION <br /> I trrehy affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> r have and will maintain a cert(ficate of consent to r which this permit is issued. <br /> self-insure for workers'compensation, as provided for <br /> by Section 3700 ofthe Labor Code, fur the performance of the work fo <br /> 1 have and will maintain workers' compensation insurance, as required by 5t!"0011 3700 of ti+c Labor Code, <br /> for the performance'of the work for which this permit is issued. My workers'compensation insuranc <br /> e <br /> carrier Mmu <br /> 1� V <br /> Cartier: __. policy Number:�,_� <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 man nerso as to became subjecAA to the workers' compensation laws of Calii'omia,and agree that if I <br /> should be ome ' <br /> ubject to the workers' wrnpensa an provisions o 700 of the Labor Cade, I shall <br /> forth ith Comp) with those provisions. <br /> Date:_` __Signature; f <br /> Printed Name: <br /> WARNINGI <br /> FA LURE TO ELCURE WORKERS'COMPENSATION COVERAGE IS UNLAWFU ,AN"S." SUDJECT <br /> AN EMPLOYER To CRIMINAL PENALTIES AND CIVIL FlNr's UP TO ONE HUNDRED THOUSAND <br /> PROV/UED:IN ADDITIO <br /> N SECTION TO HE O TI EFI COMPENSATION,INTIERESY,ATTORNEY'S FEES,ANn UAMAGIES As <br /> OM <br /> Tki 3 ZK 1044 FOR 29.LEB THAN C-57 SIGNING PERMIT APPLICATION <br /> rig tatur+r - Icensnd a 4hvrised raP2sentativel, <br /> hereby autlt.dzr. (print mama)_, <br /> [6,25-J2 <br /> ail Permit APNailcatlnn ore my behalf. I Understand this nuthsrla'rtlen is vel(et Tor <br /> ne(f)year Arid h:limited io the we[ plan d;eted on the fr ota Page of th;a ePpnc�t(on. <br />