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u019014000 YHU 14;24 FAX <br /> Vj 0 0 <br /> • • <br /> San Jnauuin County hnvrrnnnl�nt2l Health LTepartment lenft IV WNr Narnr t AI'rfiicat'on SuppiEtllert <br /> JOB ADPRESS:_/93°O w. Ura A+ LiAe kd PERMIT SIRM-0 - 8a..___. <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm(hat I am licensed under the proVlsfons of Chapter 9 (commencing with Section 7000)of division <br /> 3 of the Business and Professions Coda and my license is in full force and Pact. r� <br /> License 0: '1 a Da 0 11" (P con Date: <br /> YA <br /> Date: <br /> 8-Zfo. GS Gontra r. V W I <br /> signatrire• fits tl <br /> Printed name; <br /> WOR KE.-R 'COMPI:N9ATI DECLARATION <br /> I hereby affirm under penalty of perjury uric of the following declarations: (CHECK ONE) <br /> I have and will maintain a cerliGoate of consent to self-Ensure for workers'compensation,s provided for <br /> by Section 3700 of the Labor Code, fnr.the perromlance of rhe work for which thm permit is issued. <br /> I have and will maintain workers' compensation insurance, ns required by Section 3700 of the Labor Codc, <br /> for the performance of the wort:for which this permit Is i srued. My workers'compensation insurancr, <br /> carrier andpolicy numb pare, <br /> Carrier: (valley Number._l <br /> 1 certify thst 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 becore auhJoct to the workers' compensation laws of Califom47, and agree that if I <br /> should become subigot tothe workers'ooriipensa ion provision of SocAlon 3700 of the tabor Code, I shall <br /> forthwith Cornply wprovisions <br /> ith those provisio - <br /> 2-6 <br /> Date: 8' � O S <br /> -Signature: L � <br /> Printed Name: <br /> 'WARNING:FAILURE TO SrCuRE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AIdDSHALL JSJr:C i <br /> AN EMPLOYER TO CRIMINAL PENALTY'S AND ciVIL FINes Ur TO ONE HUNDRED THOU.-.ANP DOLLARS <br /> (5100,000,),IN ADDITION TO THE COST OF COMPENSATION,INTFREST,ATTORNEY'S FEES,ANn DArOAGES A:= <br /> PROVIDED FOR1N SECTION 5706 OF THE LABOR CODE, <br /> Tki(3I217atT10lI FOR 2,fjYFR THAN G.57 SIGNING PERMIT APPLICATION <br /> (signatvrq.or.57 licensed authorized representative), <br /> harcby authorize (print namq)—..Free <br /> to sips thty Stun.I:raquln Cor1nI:YtNell Permit,hppi:cat.inn on ml' �uhnl?. I unaorstand tail ruthorlcotion i, vaifd Sot <br /> ane Ci}y^at And is;Ilnoited to Um w.n;i;c p3tmn Iditevt or, tho front targe n*'r(kla apPlle.,Oon <br />