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-f-17-2007 04:02P FROM:ENPRO9 15305892230 TO:12099480621 Y., P,2 <br /> .moi � i ...... ... , ,,.. " <br /> San Joaquin County Environmental Health Department Unit IV Will Permit Application Supplement <br /> JOB ADDRESS: 9scb Aa✓ d L16 , 5r104L-ftV PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I em licensed under the provisions of Chapter 9(commencing with Section 7000) of Division <br /> 3 of the Business- y,7 <br /> and <br /> ddProfessions Cade and my license Is in full force and/effect. <br /> / <br /> License s: / ! 66 Expiration trate: /L1 Z3042 00 V <br /> nate: Contractor.�P✓�rOD <br /> Signature: Title: L <br /> Printed name: Oety;y 5 07/ <br /> WORKERS' 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-Insuro for workers'compensatlon, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued- <br /> 1 have and will maintain workers'Compensation 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 /> cattier and policy numbers are: � <br /> Carrier. S'-fz.-fe LO{tf4 31;1,5rt WO Policy Number. <br /> 1 certify that in the performance of the work.for which this permit is Issued. I shall not employ any person in <br /> any manner to as to hernme subject to the workers' Compensation laws of California, and agree that if I <br /> should become subject to the workers'compensatiMorris of Section 3700 of the Labor Code. I shell <br /> forthwith comply with those provisions. <br /> Expiration Date: /0 /1 /0-7 910nature: (� <br /> Printed Name: Be/-'tt/L$ v „ <br /> WARNING:rAILUAr TO uECUR2 WORKERS'COMPENSATION COVERAGE IS UNLAWFM.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTERERT,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 37OG OF THE LABOR CODE. <br /> a-TMDc1\)rJl,3 <br /> TION FOR OTHER THAN C-37 SIGNING PERMIT APPLICATION <br /> 0-n owr`�' -r(signature ofC-57licensed authorized mprusentative), <br /> hereby authorizo(print name) f�tdJC1.5 e4bu <br /> to sign this San Jostiuin County Well Pam+H Application on my behalf. I understand oda nuthorizetlan M valid for <br /> one(t)year and Is limited to the work plan dated on the front page of this application. <br /> 04"21 Ml <br /> HHD 29.02-M I <br /> 1=106 <br />