Laserfiche WebLink
S® EP 7.2003 7:38AM TREADWELL & ROLLO NO.257 P.4 <br /> yam_ �u VIKUNtm-K INC. i1Q56B7679 <br /> P. 2 <br /> San Joaquin County Environmental Health Deparithent Unit IV Wali pa"nit Applleatlon gupplbmant <br /> JOB ADDRESS: fiq l W, Israr1-- PERMIT SR#: <br /> C�- <br /> LICENSED CONTRACTORS DECLARATION ( � <br /> I hereby affarrrt that I am licensed under the provisions of Chapter 8 (comrnencino with section 7000) of Division <br /> 3 of the Business and Professions Cone and my IlcerlsO Is In fait force and effect. <br /> License : a �- Expiration Date: l�bp <br /> Date: Contractor: <br /> Signaature: C:, L!QA� 1 t y� ; <br /> - - u���- Titled 19 <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> Hereby affirm tinder penalty of penury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to.self4rioute for workers' compensation, as provided for <br /> Section 3700 ofta -"'or Code, for the performance of the work for which this permit is issued. <br /> -4-1 ave and will rain► aatln workers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> f rthe performance(of the work for which this permit is Issued. My workers' compensation Insurance <br /> crier and Policy nu_r tiers are: <br /> C frier;� 11 trA.A t �c 15�1 _ <br /> policy Number. LLX*. 105 <br /> I certify that In the pirformance of the work for which this permit is Issued, I shall Oct employ Any person in <br /> any maannbr s4.as to'became subject to the workers'compensatlon laws of C'aailfamlQ, and agree that if I <br /> should become subjjct to the workers'compensation provisions of Section 3700 Of the Labor code, I shall <br /> forthwith comply with those provisions, <br /> Date: tq- L4- 0-6 -Signature: <br /> l-J�r <br /> Printed Name: 1 2 L h� - <br /> WARNING* FAILURE tO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT �J <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP To oNp-HUNDRED THOUSAND DOLLARS <br /> ($10D,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMA(3ES AS <br /> PROVIDIED FOR IN SECTION 1708 OF THE LABOR CODE. <br /> AUTHORIZATION FORTHAN C-57 SIGNING PERMIT APPLICATION <br /> • .�1 � _ Jalgnature 00.57 licensed authorized represerrtdive), <br /> hereby authorize(print norne) �d <br /> to sign this San.loaquin County Wall Permit Appilofftlon an my behalf. I understand this authorization lit Vglld for <br /> one(1)Year and Is limited to the work plan dated an the front pope of this applicatlon. <br /> 8-20-021 MI <br /> Gi <br />