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R <br /> i <br /> San JoaquiriCoulnty Environmental Health Sarvicos,Unit JV Welt Permit Application Supplement <br /> i JOB ADDREfS S:_• PERMIT <br /> f <br /> ' LICENSED CONTRACTORS DECLARATION (.Cry) � <br /> I hereby affirm that I am licensed under tho provisions of Ch:p:er 9(commencing with Sectlon 7004)of VvWon <br /> 3 of the Business and Professions Code and my license Is in full force and effect. <br /> Liodnae#: 6 Z Expiration Date:-. r C — 0.3 <br /> dot©_ 1 Contractor: / r Ll- rD I` <br /> 5lgnature: Titio: e v { <br /> Printed name: <br /> T <br /> WORKERS'COMPENSATION DECLARATION G <br /> j t hereby affirm under penalty of perjury one of the following ee,-Iarations: (CHECK ALL THAM APPLY) <br /> I have and vel maintain a certAciate of consent tQ self-Insure for workers'crmponsetion,9s provided for by ; <br /> { Section 3700 of the labor Code,for the performance of'ha work For which this permit is issued. I <br /> f ]� 1 have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Cade, <br /> for the performance of the work for which this parmn is Issued. My workers'compensation Insurance <br /> carrier snd polic numbers are: <br /> C 1 t I <br /> CarrierxJU�}- -WA Polity Number: <br /> certify that in the paiformance of Me work for which this permit is issued, 1 shall not employ any person in ! <br /> pny manner So as to become su0ject to the workers'Compensation laws of California. and agree that If I <br /> should become subject to the workars'compensation prov(sions of Section 3700 W the Labor Code, I Shall <br /> forthwith comply with those provisions. <br /> Date: Signature; <br /> I <br /> Printed Names: i <br /> WARNING:FAILURE To SE=CURE WORKERS'COMPENSA710N COVERAGE I9 UNLAWFUL.AND$161ALL SUSJVCT <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,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS 1 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. { <br /> � r E <br /> 1• �6t1�1f~o �- Q.d <br /> (C-57 licensed nuthorliect repm%itntaftt),herepy <br /> Ito sign this San Joaquin County wall Pem It AkDllcatlon on my behalf. I Vilderstand this awlhori,*Ion 19 valid for <br /> one(1)year and Is limited to the work plan dated on Mo front page of this appacation, <br /> 5.17.2000 1 MI <br />