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FILE COPY. <br /> $an aqun1 County EnWonmental Health services, r:it N W-611 Petzn#t Application SlJpPfErn ant <br /> ...` _r <br /> E .SOS ADDRESS: P�R1�ri' $#��: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> l <br /> !hereby atiltm that f am Iicerlseet udder tho ptojrisiors of Cha ter 9(commencing with Section 7000)of Divislon <br /> 3 of file Business and praflas5fons Coda and my lfc2n=is in fail farce and e#fact. <br /> Li, nae TI: . fl 2 [ Ex irad Date: <br /> Data_ Contractor: J r �-- <br /> 7itio: l ri`N <br /> Signature: <br /> Printed nasrre: <br /> WORKERS'Ct)MPENSA7! N DECLARATION- <br /> I <br /> I hereby affirm under periafty of pciury one of ft fallovv'n d ~#arjmuons: (CHECK ALL THAM APPLY) <br /> I gave ar�d vtili maintain a c�tits a f Consent to self-In ra for workers'itompe1s�tron.as providod'for by <br /> _ <br /> ! Sedion 3700 of the Labor Code,for the perf'ormaries of t la work for which this permit is issued. <br /> ]�1 Clave end will maintain workers'compensation insurarac ,as required)3y Sertion 3704 of the Labor Code, <br /> for the performance of the work for which this pafmit is is suad. My v.�ori am'compensation hisvr=ICe I <br /> carrier and?aficy numbem are: f <br /> Carrier,Jr� p'oi3zp umber_ � • <br /> I c..ni#y that in the performance of 1118 work for which th'4 permit is issued, I shaft mot employ any person in E <br /> flny manner So as tis beCOMe SubNect to the woriters'ton 1pen$Vlan Jews of California.and agree thal If I <br /> should become subjW to the warkere compensation pr visions of Section 3700 of The Lobar Code,I shalt <br /> forthwith comply with those provisions. <br /> bate. Signature' _..._. .�.,.� . <br /> i <br /> Printed Nora% <br /> WARNING:FAILURE-toSECURE WORKERV CUMPENSATIO COVERAge IS UNC AWFUL,AND$HALL f3iftJIMT <br /> AN EMFtJ?"r I=R TO GRiiIAlNRL PEf+fALTii~S AND CIVIL FlNES Y8 4NE HUft<CJR> TiiQO3AJE[3 Dr1iLt11itS <br /> IN d1DDMON To THE COST OF COMFEHSA7t0>4,# REST,A3TORllI=Y'S MES AND DAMAGES AS } <br /> PROVIDED FOR IN SEG ON 3108 OF THE LABOR 0013C <br /> } C:r - tC-57 tlesnied hinho+[zed rept*4ttntativa),here?,y <br /> authorize 4 PL �� r.;�Y ? �-&ivj*uan�� <br /> to sign this San Joaquin CouAly Weil Permit AWIcation an r behalf, 1 understated this avthsarizatlan ie va;id fol <br /> Ong 11)year acid Is Umited to nm vmtk ptarr datad ars tho front slage of this 2pp4cation, <br /> 5.11.20001 MI <br />