Laserfiche WebLink
II � y ti <br /> V 4 <br /> JOB ADDRESS `- PIiRNlIT SRO:` <br /> J.k M <br /> LICENSED CONTRACTORS DECLARATION (LC <br /> 3 <br /> I hereby affirm that I am licensed under the provisions of Chapter S(oornrnancino with Saetlon 7000 of Division <br /> 3 of the Miness and Professions Godo) and my license is in full fora and effect x <br /> Lbvme#-, ' 74226%A2- Expiration Data: ,4 o 1-00-1 — - <br /> Data: Cont' r. _ CA61� ' 1.�am Orar..aeMokw.4 MA � <br /> Printed haul*: <br /> WORKFERS' COMPENSATION DECLARATION <br /> I hereby.affirm under penalty of perjury one of the Wowing declarations' [CHECK ALL THAT APPLY) , <br /> I <br /> l have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for by i <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> i have and will molnta'n workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> fpr the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and pokcy numbers are: <br /> Carrion Policy Number; <br /> I ce6fy that in the performance of the work Tor which this permit is Issued, I shad nal employ any person in <br /> any Branner so ab to become swipjew to the workers'comperisatlon laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of an 37 0 of,he Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: _ _Signature: <br /> Printed Name; <br /> WARNINO: FAILURE 70 SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,-AND SMALL SUBJECT 44 <br /> AN EMPLOYER TO CRIMINAL PENAL71ES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS I <br /> iSID0,000.), IN.ADD11-ION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I, %d%►..;, _its! - _ -- , (C-57 license holder), Mremby <br /> butherit* .�A ;*3 tom.,,, r of A Cz L — (go noultinQ),to alpn this San j <br /> Joaquin County well Pormit Application on my behalf: I understand th}s authorization is VAIld for one (1)yOar { t <br /> E <br /> and it Rmlted to the work plan dated on the front page of this application. <br /> i <br /> 4 TO/I@ --Vvd NOiADOtS 3`7d t?IjLL9b6PZ L� LZ A66L/0i/i6 <br /> Z0 39dd ? 00000000000 8b:90 000Z/TT/T0 <br />