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. 09/27/99 16:49 FAX Z02 <br /> r <br /> Sten Joequin County Envirovm ntat"oaRh Services,Unit tY 1}t;'oll Permit Application Supplement <br /> JOB ADDRESS:, ) PFEIMtT Sri: 0 39 <br /> LICENSED COWTRACTORS DECLARATION (LCD) <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 fand effect..f'y'N <br /> License 0 I c7f V_�_ Expiration Date: <br /> Dade. rdractur: VW D1 ,1 if f o - f j 3C . - - <br /> Signcturo• T1tbe O/il' azeK ../11 <br /> Printod name: <br /> WORKERS'COMPEWSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL.THAT APPLY) <br /> _I have and will maintain a certificate of consent tD self-insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> t havo and will maintain workers'componsyation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and <br /> (!polic numb- are: NWC �,, <br /> Carrier Policy Idumbor: , - � <br /> 1 certify that in the performance of the work for which this permit is issued, I shalt not employ any person in <br /> any manner so as to become subject to the workers'compensation lawns of California, and agree that if I <br /> should become subject to the workers'compensation provisions of S 3700 of the Labor Code, I shall <br /> forthwith comply <br /> with those provisions. <br /> Data. < / Signature: ,04,1 <br /> 4, 6, <br /> Prtnted Puma: <br /> WfAR1141MG:FAILURE TO SECURE WORKERS'COMPEMSATION COVERAGE 19 UNLAWFUL,AND SHALL SUBJECT <br /> AN ECSPLOYER TO CRIQ_INAL PENALTIES AND CIVIL PINGS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (SIOGAOOJj IN ADDITION TO THE COST OF COMPEUSAT1ON,INTEREST,ATTORNEY'S FEES,AND DACAAGES AS <br /> PROVIDED FOS IN SECTION 3706 OF THE LABOR CODE. <br /> L tC-87Itconced authadzed ropneeentcOvo),horoby <br /> authodw <br /> to algn thio Sr-at Joaquin County Wall Permit Application on my behalf. 1 undarntand thio outhorizntion io valid for <br /> one(1)year and is limitod to the worts plan dabd on the front paM of this application. <br /> it 'd i^iOti� Wd9 L =6 666 l-Lz� <br />