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01/17/2009 FRI 15:31 FAX • • Z002 San Soagtltn Co;ZF�l Etl-Health Servicma,Unit IV iNell Permit App Ilaation Suppkement I PER7d117SR#: JOB ADDRESS: LICENSED CONTRACTORS DEOL,AR,ATION (LCD) 3 oFrthe Business and Prlofess ons Code andunder the rmy license is in full force and eeec((tg��witt! Section 7000)of Division 10 Expiration Date:q ,��ff �� ^'t- License 1 ontractor. Date: - /•1 i A.QJ�/L[lL/ Title: LYS Signature: (:a7, 1R Printed name: _ WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) mpensation, as Section 370010 the Labor Cade,foe the performance tof consent to fof the work for-insure for kwhich this permit is issued. For by I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued My workers' compensation insurance carrier and policy numbers are: I Ll Policy Number; Carrier: p p person in ensation lays of California, and agree that if I I certify that in the performance of the work for which this permit is issued,I shall not employ any any manner so as to become subject to the workers'come should become Subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwi co ply with those provisions. irpI/ll .� Signature: _ 4—+L-L1 v Date: JECT t Printed Name: ANo AGE IS WFUL,AND SMALL WARNING:FAILURE TO SE -EMPLOYER TO CRIMINAL PENALTIES AND HOUSP C VIL FINES UNTO ONE ATTORNEYS EES,AND DAMAGES AS pROVI ED FOR IN SECTION 3705 OF THE FLABOR CODE. ON, (C-57 lieens a "orized rePresentative hereby 1 (/f authorize , V , to sigma this San Joaquin County Watt Perrot ApPiica on my behalf. t understand this authorization valid Tor ar and is limited to the work lan dated on the front age of thls application- _. one(1)Ye_ .- N WO?J� WdPS°D l hC�6 I-9Pr-Et l