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VO/ 90/ZUU0 hitt 14:24 FAX X002 <br /> r/ <br /> r San FoaC[Uin 6uunty Ennviroilmenial Hem(th Department IIrill IV WclI Permit Appficatiort Suppiemer•t <br /> JOB ADDPESS: �.._C2ran �i�e ,P> lef� tr s� ; © o <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Divislon <br /> 3 of the Business'andProfessions(:oda and my license is in full force and ffect <br /> License#: `0 Exppi iorl Delte: <br /> Date: o '2fo.' 6S Contra tar. <br /> 5ignatfire• ��° <br /> Printed name: <br /> WORICF12S' COMPENSATI DECLARATION <br /> I hereby affirm under pensatty of perjury one of the follolving declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure,for warkers'campensation, as pioyided for <br /> by Section 3700 of the Labor Cbde, fur the performance of the work for which this pamitt is issued. <br /> , •I have and will maintain workers' compensation insurance,Rs required by Seotion 3700 of the. Labor Code, <br /> for(he performance of Nie wort:for which this permit Is is^ued. My workers'compensation in�suraan}co <br /> carrier anpolicy numb s are- /� O I <br /> Carrier: GG �` PalleyNulnber.,-I-IN <br /> —11A <br /> certify that in the performance of the work for which this permit is issued, 1 shall not employ any person In <br /> any manner so as to become eubjbct to the workers' compensation laws of Catifom47, and agree that if I <br /> should become subjoct to the workers' colnpensa ion provisions of Soctioii 3700 of the Labor Cade, I shall <br /> forthwith Comply with those provisions- 7 <br /> Date: _._ _Signnture: ` ✓��/ti -- - <br /> n <br /> Printed Name:' <br /> 'WARNING:FAILURE TO SCCURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AtdD$HALL UBJEC i <br /> AN EMPLOYER TO CRIMINAL PENALT9PS AND CIVIL FINDS UP TO ONE HUNDRED THOU.§AND DOLLARS <br /> (SJ00,00c,),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FLES,AND DAfAAGES A:; <br /> PROVIDED FOR1N SLCTION 3706 OF THE LABOR CODE. <br /> THORIrZATION FOR 0, THAN C.57 SIGNING PERMIT APPLICATION <br /> _;z7 ti - (signature of(:-57 licensed 7uthoriznd represenfatly®), <br /> hereby aufitorizo (print namat_,.L.. . — -----— -----"-- --- <br /> to Sipa 2hra Still.l,raqurn County Wall Parmit Applu:atinn on m]: I understand f:ai: sUthorizotion i^, vnild, for <br /> a: e ti)y^i{;and h:flnri'hEd m tlur VI'.rn�fi pi,ln�ste;a ar,the tY'rmt p.rr,•e n^•reefs apitltrrtNon <br />