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Sar:Joaquin County Environmental Health ftrylCes,Unit IV Woll Pur(nit Appilcation Supplement <br /> .)C}�t ADDRESS' <br /> 1=>aS: Sol .SPERMIT SR#: <br /> t LICENSED CONTRACTORS DECLARATION (LCD.) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commoncing with Section 7400)of Division <br /> 3 of the Business and professians Core and my licenae ie In full force and effect. <br /> License#; Expiration Date: <br /> Data: b/ ractor:cont <br /> _.._. <br /> Signature- - <br /> ,t , r/�� Tltl��iuiv�*t <br /> � ... _ . __ — <br /> r <br /> Printed name: <br /> WORKERS' COMPENSATION[ I3ECLARATION <br /> I hereby affirm under penalty of parjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-unsure for workers'componsatlon,ah provided for by <br /> SaoVon:3700 of the Labor Code,for the perfnrmanrs of the work for which this permit is issuuod. <br /> ave and will maintain workers'compensation insurance,m required by Section 3700 oI the Labor Code, <br /> for the performance of the work for which this pemill.is lair uwJ. My workers'compensatlan insurance <br /> carrier and policy numbers are: <br /> Caller: �/+„+4+J� JS• _ ... . ...policy Number: ✓Yl//� ���/t S Z 6 D 0 <br /> ✓I ce+rUfy that in the performance of the work for which this porMit Is issued,I shall not Hnrpioy any person in <br /> any manner so as to become suhlact to the workers'compensation lawn of California,and agrees that It I <br /> should become subject to the workers'compannatlon provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply wall those provisions. <br /> Date: OJIV-OZ o f --Signature: r a� U _ <br /> Printed Name' . trlf- '� <br /> WARNING:FAILURE TO SECURE WORKERS'GOMPGNSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDREt]THOU&ANO DOLLARS <br /> TO RE COST Q THE IHCCrCOMPENSATION.INTREST,ATTORNEY'S FFFS,AN13 DAMAGES AS <br /> PROVIDED FOR IN GTI <br /> „_,(C-61 Gcenred authartzed ropmr&ntetive).hereby <br /> to*ion this San Joaquin County Weil Pormit Appticauen an my behelt. 1 undamtand tMe authariratlon is valid for <br /> one(1)year and is limited to the work plan dated on the(rant page of this appllr000• <br /> SAA 2000,I lutes <br />