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I G _t _EtOa 1�:;' 916861-� tjFJ - S==DF <br /> I <br /> San Joaquin County Environmental Health Department Unit IV Wuil Permit Appllcntlon supplement I <br /> JOB ADDRESS: /7,151'J rSi _ PERMIT SR#: M D I <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Sectic:n 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and efect. <br /> License 9: _SCP �J Z� _ Expiration Date: <br /> Dare �b G Contra or: <br /> Signature: /� TitIA: -aft 6—IC-1 <br /> Printed name - <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby a"firm under penalty of perjury one of the following dw Lmations: (CHECK ONE) <br /> I have and wtlI maintain a certficate of consent to self-inure for workers'compensation,an provided-'or <br /> by Section 3700 of the Labor Code,for the performance of the worts for which this perms;is issued <br /> -V I have and will rnalnt©In workers'compensatlon insurance,as reqjirod by Soction 3700 of the Labor Cade: <br /> 'or the performance of the work f,-)r which this permit is issued. My workers'compenItlon Inurarce <br /> carrier and policy numbers are: <br /> Carrier;_�I�;�-c� (y\�)TU Polley _ <br /> T �---- I <br /> i certify Vial in tho performanco of the work for which this permit is issued, I shall not employ any per-:en it) <br /> any manner so as to become subject to the workers'compansaGci 1 laws or Calitornia,and agree that if I I <br /> Should become Subject to the workers'compensation provisions of Section 3700 of the Labor Corte I shall <br /> `orthwith comply with those prnvlr>iflns , <br /> Lxpiration Date: (p �Q Signature: <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL 51.144-CT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> 1`zloo,o00.),IN ADDITION TO THE COST OF COMPENSATION.INTEREST,ATTORNEY'S FEES,AND 4AMAr,FS AS <br /> PROVIDED FOR IN SECTION 3706 OF THF LABOR CODE. <br /> AUTHORI TON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> —(9 ionature WC-1,7licons2d aufhorl_zadyro-p/re-no-itativo) <br /> heroby authorize(print nrmr) <br /> I - <br /> to sign this San Joaquin County Walt permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and IL limited to tho work plan dated on the front page of this application. <br /> 8-29-U21 MI <br /> L•11U:9-02 oo <br /> 6,21/!14 <br /> 2/2'd 02t70ti989ti6:01 t7LSt7 L22 OTS 9NI-ldt4US HOISID9I icl:k]O'Jd t72:2T t7302-98-100 <br />