FIELD DOCUMENTS_FILE 1 - Laserfiche WebLink

Home Browse Search

JUL-25-00 WED 5: 24 AM M. D. -'- r . FAX N0. 91 a-852 9535 P. 1 87/24/2808 10:13 2090+1118 AGE STOCKTON PAGE 03 JOE:AODRESS:.15&15 50AJ41, Irk 4t1/iteii • PERMIT; SIt#:. OOZ391�q i LICENSED CONTRACTORS DECLARATION (LCD) I I hereby affirm that I am licensed undo the provisions of Chapter 9(commencing with Section 7D00 of Division 3 of Uta Business and Professions Code)and my license Is In full force anndd,effect, i License#: V-`„ Expiration Date: lY —J Foo Date: Z��.t'�(� �JContractor, 11qt r Q / Dr; hm C--/)Y. cow Signature: �/� Title-,Title-, «$r l+r W Printed name: 4 r /f /r fll i WORKERS'COMPENSATION DECLARATION , I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) I have and will maintain a certificate of consent to self-insure for workers'Compensation, as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. i have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, l for the performance of the work for which this permit is issued. My workers'compensetion insurance wrier and °policy numbers are: Irl. Carrier. d I1d Policy Number: I certify that In the performance of the work for which this permit is issued, I shall not employ any person in I any manner to as to become subject to the workers' compensation laws of California, and agree that it i i should become subject to the workers'compensation provisions of Section 3700 of the Labor Code. I shall forthwith campy with those provisions. Date: Signature: i Printed Name: WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5100,000.),IN ADDITION TOTHE COST Of COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. i, Gv W�rt� /"t(�0'��/ J � F I (C-57 license holder),hereby suthoriza�&l _r C- of to sign this San Joaquin County Wall Porrnit Application On my behalf. I understand this authorixaUon Is valid for one(i)year and is limited to the work plan dotod on the front Page of this application.