Laserfiche WebLink
06/15/2009 15:42 5306766005, STRATUS NO CALIF ( � PAGE 02/02 <br /> • I <br /> San Joaquin County Environmental Health hDepa*tment Un' <br /> N Woli Permit App <br /> h!1:1onupplement <br /> JOB ADDRESS: <br /> ISfoSs� 5. � PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force a1nde f�. <br /> License#: <br /> —!(U U7 Wirstion Data: <br /> Date: (°��S/U5 Contractor: <br /> voudl.0 I)�ji <br /> Title: <br /> Signature: - <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certmfcate of consent to solf-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 will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this pertnR.is issued. My workers'compensation insurance <br /> carrier and Policy numbers are: <br /> �_,Policy Number: C� <br /> Cartier:_�j` person in <br /> 1 certify that in the'performance of the work for which this permit Is issued,I shall not emand ploy arty th <br /> sany mannr so 8.4;to become subject to the hould beecome subject to he Workers'compensation P ovis onnssiof Sections'compensaton laws of 3T OCalifoofithe Labor <br /> should <br /> lmshall <br /> forthwith comply with those provisions. <br /> D _loot_Signature: <br /> Ettpiration Data: it <br /> Printed Name:COMP _ <br /> WARNING: <br /> FEMPLOYER TO TO SEC pE WORKERS'ES AND CI1tIL F NES UP 70 ONE HUNDRED THOUSANDSATION 00�ERAGE 15 UNLAWFUL� DDOLLARSUBJECT <br /> AN _ i <br /> AS <br /> ($100 DED) FOP, DITION TO INSECTION HE COST <br /> THE OFlCOMpABOR SSDE•ON.INTEREST,ATTORNEH'S FEES,AND DAMAGES <br /> PEitM17 APPLICA <br /> AUTHORIZATION FOR OTHER THAN C-51 SIGNING <br /> (signature ofC-57 licensed authorized representative), , <br /> i' /{ �Ati �a, Lev` p,rA 5,&V-0L . Suj(e�a <br /> hereby authorize(' int name) <br /> uin County well Pemtit APplieagon on my behalf• i understand this authorization is valid for <br /> to sign this San Joeq <br /> one(1)year and is limited to to work plan dated on fhe front page <br /> Of this application. <br /> 8-29-02 f MI <br /> EtrD 29-02-001 <br /> I621104 <br /> i <br /> l _ J <br />