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01/09/2003 12:33 20946711 AGE STOCKTON ^ PAGE 02/02 <br /> JAN_ 9-09 FRI 8. 39 A M. D. �""'� FAX NO. 916 9558 r tlP. 2 <br /> $3171A1Z003 13:al 2i39s6711I,t� <br /> pGE STp�❑i t <br /> San Joaquin County 11n0ronmental Health Department Unit IV"Wall Permit Appficatton SUpplentsnt <br /> J00 ADDRESS, �] PERMIT $R; : <br /> S7a %Z-Mty I <br /> UCENSED.CONTRACTORS DECLARATION (LCO <br /> I hemby eftlrm that 1 am llcansed under the proyislwta of ChWiI: 9(Commencing with Sec6on 7000)of Divlston <br /> 3 of ilio Business and Processions Code and my license is in fug farce and effect. <br /> Licent o z(it/ � Expire n Daae:-- 0___3 0 a� <br /> Date: onlractor: r e I ✓�s; h�. �� <br /> Signature: Title:, <br /> Prldted nsrne <br /> WORKERS' (COMPENSATION 13ECLARATION <br /> I t*rtby affsrrn under penalty of pedury one of the following dWor0ons: (CHECK ONE) <br /> I have end waif maintain a cartlticate of consent to salf-insure for workers'aompansatlon,ass provided for <br /> by Section 3700 uF the Labor Coda.for the performence of ttie work for which this permit is%Sued, <br /> i have arra wlti malritaln wor}cera'companwban lnsurence,rte required by So0on$700 of the l.akbar Code, <br /> for the performancO of the Work for Mich this purrnk is Issued. My workers'oompanSation irl9tlrance <br /> Lamar and policy numbers srts- <br /> Carrier5f_t- F� .Paucy Number: l 15 <br /> I certify that in the performance of the vmrk for wNch thio permit is lssued, I ahsll not employ Any person M <br /> any manner so ae to become oubj of to ft workers'corltpengsgo c laws of Callforrlie,ang agree that If I <br /> should beeorne subject to the Worker$'c:ompemabon provisions of Sedan 3700 of the labor Code.I shall <br /> fonnwrth comply with those provtsion6. <br /> Dote: Signature: �T — <br /> Printed Norrie: <br /> WARNING:FAILtlRE TO OCCURS WORKERS'COMPENSATION COVERAGE IS UNLAWFut,AKO SML SUSJFCT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ARID CIVIL MES UP TO okW MUNDRI=D THOUSAND DOLLARS <br /> (Sil)8009_h IN ADDITION TO THE COST Or C0NPEN9ATf0N,INTEREST,AIrTCWNEY'9 PEES,AND DAMAGES A6 <br /> PROVIDRD POR IN SECTION 3700 OF THE LAWR CODE. <br /> AIJTHOR ON FOR DSR THAN C-47 SIGNING PERMIT APPLICATION <br /> I, 1q,f k {signature afC-5T licensed authaftod rqueeontativo), <br /> hemby authorira(prink name) �F <br /> to sign this Bort Jopquin CountyWell Permit Applifttlon an nay behalf. I understand thlo authartcstlon Is valld Fpr <br /> 011Q(1)ytrsr and 16 liml6ed to the work plan dated en 0%irony p938 of this appitcalion. <br />