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06/15/01 FRI 08:09 FAXa 001 <br /> )� a �. e� <br /> ,•1a�o1 T 1s:as FAX Q �� <br /> ,06/14/200.1 12:59 6834 3 �r C7 <br /> 04 <br /> San Joaquin Coonty En�4t1Rje <br /> } ntal Flealth <br /> JOBService:,, U­Iv Wel1 f 1117nit Apptlea tlon SL <br /> �d��ICss: ���� �� .��' pPlem@ht <br /> C-IIPERfVIT SRS: <br /> LICFNSEID CONTRACTORS DECLAPJ,7-0N (LCD) <br /> I h®reby affirm that 1 am licensetl under the provr$ions of Chapter , ao <br /> 3 4f the Business and Profps5;9ng Cote ,1nd trt Il <br /> Yrsc is in iuil for( ~ 1, "np with sectir5n 7DOd)of Division <br /> License ; and ^"''et, <br /> — „Expiration Data, <br /> Date. <br /> � tlll•�c}or: <br /> Signature. <br /> I'rPubed name; Title-1�xe��^� <br /> Q. <br /> WORKERS' COMPENSATIOnr DP LAR IT oN <br /> I by arffrrn under penalty op <br /> perjury one o1 the foliowiR da,.larations: 1C I-". <br /> 5 CK ALL THAT APPLY) <br /> I have an f rnalntafn a ae�r•tiflr of <br /> con <br /> S4°tiQn �7oD o �bpr Code, far the sent to S„ff-insure fOr worker;' <br /> perforMonc:❑1 Ula work for wr..,� om'7ensation-3-1511.1de.fpr b <br /> I haUe and will maintain v:,v hrs . �s issued, Y <br /> forthe performance of thework om,Nnsation insurance, as re <br /> carrier and Policy humbers are: fore this permit is iw:,u SC <br /> carrier 3'/pU of the Labor coda, i <br /> Y 'cornpen5atlot, insuPanva <br /> Carrier: aN <br /> _, _Poiiey mbar: <br /> 1 certify that in the —- —• —_ j <br /> br�bf rman the work for rrhlcrT this herr I <br /> $ny mannerso�� to be @ 54bjett to the worker mit is • <br /> Should become sub- s'eom en uF �hsl! nor. ernp;oy any person in <br /> forthwith tom to the warkPrs' com P Sats°^ I G�lifornia <br /> iv)thocg ravisio . P4nsatipn provi:�ions of Sac';} . ' and Agree Mat If I <br /> P n_.. a of tho Laber Code, t shall <br /> Date, <br /> Slgnat I.Ir4'!' <br /> Printed Nams­ <br /> WARNINGa FAILURE To srcURE WO � <br /> ApN EMPLOY�a 70 CF2IMINAL PFNALTRIE'S ANtI CIVILCOMPEF1N1 si up G�VEft 1 <br /> ($T00,t)p0.). IN ADOITIOHt TO THE COST OF Gb T bN� ;_AW . <br /> PROVIDED FOR IN C MpEtiSATION•tNT., HUN'.=: THOUSANp p UBJECT <br /> TIQN 37ps Q YHE LSBC)p CODE, 'RrWr,A-rTc r; irl"S FEES pNp LLgaS <br /> DAMAGES AS <br /> (Si9ratUro ofC-57 r;_cased autho ' <br /> hBmbyouthori2�(Print hams} �, �•�.� �y..�_ rr�ed rLpr�scn <br /> tOslgn this San Joaqulh Count Wa <br /> Y II Perron 4apl►ration on my bc:iaif- I <br /> she IY)year and is rt 4r'�'��ra'C d this�L+'hor;zatia ' <br /> Mft�d to tha Mark purr d,.,ted oh the frontb p n b valid for <br /> 5,'Ii�20001 Mf G 9 4f this apprl:'; an_ <br />