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10111/2804 15:19 209--5.9-2225 <br /> MODESTO ATC PAGE. do <br /> San.toaquln County Environ., Mal Health Depwwwnt Unit 1V Will Parmlt AppNaaden Supplsment <br /> JOB ADDRESS: 1S ;e �.. L:.,��� f"--r--- PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATION (LC— <br /> I hereby affirm that 1 am licensed under the provisions of Ctieptar 9(commencing With Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in kd to and effect. <br /> License n o -2 —-- F-viration Date: I O <br /> Date: Contracto <br /> f_ <br /> r. <br /> �-- Title- /t7 ane A,---J, 5 N1lC <br /> ttA)I <br /> Printed name: �l r <br /> WORKERS' COMPENSATION DECLARATION <br /> I heraby affirm under penalty of perjury one of the**mMng declaraft : (CHECK ONE) <br /> 4 t have and will maintain a certificate of consent to sdF insure for workers'compensation,as Provided for <br /> by Section 3700 of the Labor Code.for the performance of the work for which this permit is issued. <br /> I have and wit maintain workem'compensedon insurance.as required by Section 3T00 of the Labor Com. <br /> --or the performance of the work for which this permit is issued. My workers'compensation <br /> carrier and Policy nnum}bens aro. <br /> Carrier: W i( I `7 - Policy Neu AW. 6� - <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 as to become subject to the ww%6m'o0rrrpenaation taws of California.and agree ttlat;f I <br /> should become subject to the workers'Compensation provisions at Section 3700 of the Labor Code,I shall <br /> brthwtth comply with those provisions. .17 <br /> Date• )d sklr' <br /> Printed Name- <br /> WARNINCr:FAILURE TO SECURE WORiERS'COMPENSATiON COVERAGE iS UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER To CRIMINAL ppNAL1=S AND CtWL Firm up TO ONE HUNDRED THOUSAND DOLLARS <br /> (til D FIN ADDITION TO OR t T10N SHE COST LABOR QOOE. .INTEREST.ATTORNEY'S FEES.AND DAMAGES AS <br /> PROVIDE <br /> j AUTHORIZATION FOR 4r THAN C-37 SIGNING PERMIT APPLICATION <br /> f.U'7Vi f —�.1 (sipMntun ofC47 Ikanswi atrtfrorfaad nsP1*s0rtstM). <br /> tlsroby authafsa(Print 1W., — <br /> w sign this Stn Joaquin County Wall PsMalt AppMcs0on on my behalf. 1 undsrsfand this suthorfsat m is valid for <br /> pea(1)Vow fold Ia limited tp thoWelk Plan da0u'on ttrs trent POP of this tPPIIC>>l - <br /> s,Zg•421 MI <br /> z 'd SILSEIESZ6 UOPIWM Rjew dES :bO b0 it 400 <br />