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PAZ <br /> —San Joaquin Cosh Bnvtra..m�ntawi H*alth Sarvfces,Unit IV Ws t Permit Apel#cation ujtptemaret <br /> JOB ADDRESS: kc PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (1cP) <br /> 1 hereby wfkrn that)wrn liaeneeci under the provisions of chapter a (oueremernoir.Q with Seution 7000)of DIVIs►on <br /> 3 otthe evsiness and Proressions Coda and my Iloenes is In full force and effect,.,� <br /> Lftnsm#: "7 Explradon Date: ,', __ - • - - <br /> Da►e _ 4idu <br /> pntractor: 1/7Printed na <br /> WORKERS'COMPENSATION DECL.ARAVON <br /> 1 hereby affirm under penwity of perjury on of the following doclararkens• (CHECK ALL THAT APPLY) I <br /> I here and will maintain a partif csto or consent to seta-Insure for workers' compensation, as provided for by <br /> Section 3700 of me Labor Cotte,for the porfomvnce of the work for which thls permit is Issued. <br /> I have and wilt rrYditain wur'ksrs'avmpansaltion insurance,as required by Seotion 3700 of the Labor Codo, <br /> Tor the porformome of the work for which this permit is Issur.-O. My workers' compensation insuranco <br /> cardw and poky numbers ore: <br /> Carrier: 11911cy Number:�� ,,;- •.1r�„;4�1 — <br /> i cerdty that Irl the performance of the work for which this permit to issued. I shall not employ any parson in <br /> any manner so os to become svbjtd to the ww"rs'compemollon laws of California, anti agrab that if I <br /> showd boeome suljeot to the workers'comt>ensatiori provisions of 3 bn 3704 of the LaDor Code, I shall <br /> Whwlth pomply with Vwse provisions. <br /> Data' St�ltatturer__ <br /> Printed Nerne, <br /> WARNING.,FAILURE TO SECURE WORKRKS'COMPENSATION COVERAtiE IS UNLAWFUL,AND SHALL SUBJECT f <br /> ANfiPMR.EroM To CpWMWAL pENALTWS AND CrvIL Fiu s UP TO ONE:HUNDRts'O TfJOUSAND PQLLARs <br /> i 10400, ICOR I <br /> .),IN DN 87014 YO 3706 OF FLIOU t IIATION,INTEREST,AT7'ORNSY"S FESS'.AND DAMi1AC:LorSpR*VA9 <br /> I 1 <br /> 11--y <br /> _ _c-6Y ticsTh <br /> author`rrod rvprsrtn firs, Iwraby <br /> I p <br /> U Z <br /> auelanu <br /> to vign this Ban J*9cluin CourAY Welt Permit APP110 ion on MY bohrif. I understand this authafttatlon to valid far <br /> stir/4 eon end fs Iirltlfep f•Uw stork lin dad on the__ _ tpa a�_-_6f Fjli*• IlcatFon. <br />