Laserfiche WebLink
■0 0 /16/2006 THU 10:40 FAX Q001 <br /> San Ja�c{rrirt GvaerFty Envire7nrrl=°rrgal I fcaith Gee,wtmwnf Unlit IV Wall Permit AI)Pli-atinrs 511PPIC11W -t I <br /> JOB ADDRESS:_ � �' rU l�I_�G PERMIT <br /> LICENSED GONMAETORS DECLARATION (! CD <br /> I hereby affirm tliat I am licensede <br /> d under the provisions of Cli�pter 9 (commencing with Section 7000) of Divi�31on <br /> 3 of the Business and Professioris Code find my license is in full force an 41f-,;t- <br /> ou <br /> License#: t Ori _ F=xp. tion Date: — _ <br /> Crxrtra or. � <br /> Date:_ - <br /> - <br /> Signature: <br /> Printed Mame: ` <br /> WORMRS' COMPIRNSATI DECLARATION <br /> 1 hAreby affirm under penalty of perjury unA of the following ch(llzrations: (CHECK ONE) <br /> r have and will maintain a certificate of consent to sf-,fan,um for worker::' comperisalian, as proyideG for <br /> by Section 3700 of the Labor Code, for thr- perfomrance of the work for which this permit is issuF1d. <br /> I have and will maintain workers' compensation insurance, ns required by Seotion 3700 of the Labor Code, <br /> for the performance of the work torwhich this pPrnut Is issued. My wokrers'cOrnponsation insurance <br /> carnal an' policy mini s are: LL <br /> Carrier: L Policy Number:��`"101 '~ N <br /> 1 cFitify that in the performance of tho work for which this permit is issued,i shall not ivrnploy any person in <br /> any manner so asto bccdrfle subject to the workers' compotissation lawn,of California, and agroo that if I <br /> should became subject to the worict rs' cornpen4a•on provisions of Sectlon 3700 of the Labor Cade, [shall <br /> forthwith ttornply with those provisions. <br /> Date: Signature: — <br /> Printnd Name:' <br /> 'WARNING: PAII_URE TO sL.cuRE WORKERS' coMPENSATION COVERAGE IS UNLAVYFUL,A D SHALL SUE3JECZ <br /> AN EMPLDYEt2 TO cRiMINAL.PENAL-11Eo ANN CIVIL FINE$UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S1 u0,000.),IN ADDITION TO THE COST OP COMPENSATION,IN fEREST,AT'i-ORNEY's FECS,,!1ND PAMAGES AS <br /> pROVIDED.FOR 1N SECTIUN 3100 OF TVIE t.AI3:0R CODE. <br /> TSI RIZA.TION FOR O•T-, R THAN C,67 SIGN NG PERMIT APPLICATION <br /> �(%Ign�ituro of,-51 licansEw authorized repre>;entgtiv®), <br /> I, Y <br /> �i <br /> horeby authorize(print n;+mal___ <br /> � p .�nr1 thi_c�ul,Icu�lz�tflnn <br /> to�igri+4h6a San Jr0aqu;n County Wolf P2rrnat Appfl'rc:cflon on 111Yy bE:lraiforf. Yui c9ar.l <br /> o��•(i P y?FAY raaml Is lirriUcd to til^ti°ork Pk111 clawed ori thy--L§'Fovii pat;r of ti?. ;gpp1,R-zd1Lm1. <br />