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zl <br /> k)L) U <br /> r <br /> Gil2 X /Smt Jonquln CountyEnvlronntontal Hoatlh Dnpartrnont <br /> nWRI.L &BOR�rIIN�NG PERMIT APPLI/CA(T,,II�O��N SUPPLEMENTALRESS: O O-1 V !lA(Ck LAgP ST�KT011 PERMITSIR#/ l0 36 �U <br /> ! <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I horoby affirm (hat I ant Ilconsod tmdor (he provisions of Chapter 0(conuTloncintl VIII) Section 7000) of <br /> Division 3 of the California f3LIS16098 and Professions Code and my license Is In full forre and effacl• <br /> lAconsoip 7(Q() / GxpDale:, <br /> Signature: �-�.,iJtsi4z4�ti�c�-:-- '(ilia: ��J�A-Si rM.an�` Q <br /> RrintNamo: <br /> WORKCRS' COMPENSATION DECLARATION kE <br /> I hereby afflrrtt undor penalty of Perjury one of(he following doclorollogs,; (clincic one) <br /> I have, and wlll Inahttain a corliflonle of consent to soli losu(e for workers' componsadlon, as ` <br /> �invided for by Socilon 3700 of filo Labor Code,''for the pefformanoe of the Work for which lilts r <br /> pofailt Is Issued. <br /> l <br /> 'X _1 have and will maintain workers' cornpansaI[oil Insurance, as requlred by Section 3700 of'lho <br /> Labor Code, for the perfgnn oleo of alta avork for Which Ihls,permlt Is issued. My 'workers' <br /> rompensatlon insurance carrlor and Kelley numbers are; <br /> bartior:_,"j j, uxla Policy Number: <br /> I certify that In (he pofformtnco of the work for whloh this porntll Is Issued, I shall rot employ arly <br /> .person In any manner sons to beconio sul)Joct to tho workers' compensation IaW of.Calik n)fa, <br /> ,and agree NMI If I should bOCCTRO subject to workers'compensotion plovieiohCL of Secllon 3700 of <br /> the Labor Code,J shall(Oiihwilh comply Will those provisions. <br /> Exp, Dale: {b t,. t`a_ SignaturO:�T�t j ___(t�(Qtq��rrMf� <br /> PrintNamo; nM`n Iq -AL <br /> WARNWO:FAILURE TO SF.CIIRE WORKP,RS'COMPENSATION COVEnAOE 18 UNL A K,ARD SHALT.8UHJECT All UMI'LOYLit TO <br /> CRIMINAL PENALTIES AND CIVIL 1`816 UP TO 6500,000,IN AOD2TION TO im COSI'OF COMPENSATION,INTL'Ra3T,- <br /> ATTOPRPY's I1a23,AND nAMAaE8 AS PROVIDE ,FOR rr13F.CTI0N 3708 0(THU LABOR CODE. ` <br /> AUTHORIZATION FOR OTHER THAN 0.67 SIGNING PERMIT APPLICATION <br /> (Signature of C•5711consad nathorlxod toprosontativo), { <br /> hereby author o(print nano) y�H t�A ( I y.. g r <br /> }2f �/ fo sf 1n itis San Josr. Count Well – l3orhl permit <br /> Application on my Whall. I undorslmld this nuthorixotlon Is vnlld for.imo yoormid Is Iimltod to the work <br /> pIRTI datod on lho front pogo of this application. I <br /> T IUJJUCliN10 - ed ll Pi Flflt NP <br />