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Son Joaquin Coun E V'ro rrien -HeaRh S*vlces,unit IV Well Pamlt A <br /> tppBcahon Supplement M <br /> F <br /> JOB ADDRFSS: -t� � s g/PERMIT Ste: Jl <br /> LICENSED CONTRACTORS DECLARATION (U-0) <br /> I herehy affirm that I am licensed under the provlsibns of Chapter 9(commonaing with Section 7000)of Division <br /> 3 of the Business and prcofeasion_a Code and my licnnae is In hall tome and effect. <br /> Jt]crsnee#: <br /> 57 Expiratlon Rate: <br /> o ; /�•tz�n ��r c.tl,.sa Gpy� <br /> pate: d y'a Z' Contractors!✓ <br /> Tit[ _forte++Signature; -_T - <br /> r( � <br /> Printed name: C ''�'zi0 di+-EfU211?) <br /> WORKERS' COMPt~NSAnom nECLARAIION <br /> I hereby affirm under penalty of perjury anis of tl.,e tbRowing declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of 00risent to sGH-insure for workers'comWl:ria atlon,as provided for by <br /> Stiodon 3700 of the Labor Lode,for the performRrIM of this work'or which this permit iii ist;uOd. <br /> ave and will maintain workers'compensation insurance,as IV41uired t,y Section 3700 oI the LaborCode, <br /> for the pertormance of the work for which this permit is ia,autld. My workers'aompansattarr insurance <br /> carrier ano policy numbers are: <br /> Carrier: �- � --. . .. policy plumber: �. _ <br /> I ClrUfy that in the perfomaance of the work for which this parrrait is issued, I$hall nol amploy any person in <br /> --any mannpr so as to become suplact to the walkers'oompensatlon lawn Of Callfomia.and agree that It I <br /> should become subjert to the workers'compensation provtgitsns of Section 3700 of the Labor Code, I ahrall <br /> forthwith comply with those provisions. <br /> p -px'0 w r Signature: <br /> Gate: r— <br /> Printed Name' <br /> WARNING:FAILURE TO 9FCURF WORKERS'CO L FINES UP(b CINSATION NE HllNIDREC?7NDu�ND O "GE 13 UNLAWFUL�ANO SHALL SUBJECT <br /> AN EMPLOYER TO CRtiY11NA[ pFNAL1IiaS AND C AS <br /> (¢1tl11,t10q.1IN AjiwinoN To THE COST of COMPENSATION.INTEREST,A�prttNlrY'S FFFg,Allt];y►>,�ylAGES <br /> pp[lVtDEU FOR IN SECTION 374ra OF THE t,gRUt;CC1L'fE. <br /> (C-67 licensed sttthartzad razp sontatrve?.horoby <br /> authartim <br /> to si this San.taaquln Courtly Wall Pormit Apptleerl#on ora my pQ}t,E<It. t llndorstand thle autharixat101s is valid fat' <br /> � • <br /> one(1)year and is limited to the work PI1m.dut''d on the TMonit Pace of this appIltagor, <br /> fe <br />