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San Joaquin Cou ...: <br /> My.EnvlronmeMel Health DePartivent.Unit IV Wall Permit Applbatbn:Suppbmsntal <br /> JOB ADDRESS: 2535,5 /U. ,Hgrv/ 99 PERMIT SR# <br /> A�or��.ta, L1sl�i'{rrtq <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the.provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license Is in full force and effect. <br /> License.#: - -1 l�n 1 q Exp Date: <br /> Date: 1 —\—t7 q Contractor: b)bb(A <br /> Signature:Na r., ,., 1�,�A�o.O�.u. .t Title: JJ <br /> Print Name:. nllir% R- l.lnncil , a <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit Is Issued, <br /> Y_I have and will maintain workers'compensation Insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is Issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrler_tatw ��Mtlloollcy Number. , `gyp-1�p <br /> I certify that in the performance of the work for which this permit is issued,I shall not employ any <br /> person in any manner so as to become subject to the workers'Compensation law of Califomia,and <br /> agree that if i should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date:- _l 0—\ - 1.l] Signature: �L1B�liLit d <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORIGHIS'COMPENSATION COVERAGE E UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER To <br /> CRIMINAL PENALTIES AND CIVIL PINES UP To$100,000COMPENSATION,INTEREST, <br /> ATTORNEYS.FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LASOR.CODE. <br /> AL(THORIZATION FOR OT ER THAN C-57 SIGNING PERMIT APPLICATION <br /> t' (signature of C.ST licensedauthortud representgovej, <br /> hereby autho print name) �/ 5 <br /> to <br /> sign this San Joaquin county Wall Permit Application on my behalf. 1 understand this authorbudion Is valid <br /> for one year and Is limited to the work plan dated on the frond page of this application. <br /> 812M21M1. <br /> END 2WH 1115077 <br /> WELL PERW APA <br />