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Poi t;7)407 : 13: 26 630676600E STRATUS NO CALIF <br />mut nu UZ <br />n <br />SaJoaquin County ErlvlronmanFal Health Department Unit IV Wel) Pe1'mlt APPlicatlon Supp Wer>itSi59� <br />JOB ADDKESSZ _L �41Jf� �)r(l��r�� 5 , PERMIT SR#:/" -6,/ 1 <br />LICENSED CONTRACTORS DECLARATION MLP1 <br />I hereby affirm that I urn licensed under the provisions of chapter $ (commencing with Section 7000) of Division <br />3 of the Buainesa and Professions Code rind ray lieenco is in full ford and G*ct. <br />t_k=Se #: XZ)_-;� Eviration Date: icZ 31 <br />Date'. Contractor: <br />�^� 1 <br />----- I h 1A'7----, _ Titltr' <br />Printed name: <br />WORKERS' COWENSATION DECLARATION <br />I hereby affirm under panalty of perjury one of the following dedamdons: (GHECK ONE) <br />_ I ha4e and Wia maintain a certificate of consent to self.Insure for workers' compensation, s i Provided far <br />by Section 3700 of the Labor Cede, for the performance of the work for which this permit is ssued. <br />ho Rcur lwoby c�Labor da <br />h this rrnissued Mywokers'ompensatio nourance <br />for the p®��hoe of the work <br />cattier and policy nrlmbers are: ( <br />Carrier: O <br />--1-�� Policy Number: <br />00 <br />1 certify that in the perfomuanGe of the work for which this permit is issued, I shall not emplAY of Y person in <br />any manner so as to become SuWeet to the workers' oampensaHon Laws of oa1"ifornia, and agree that if i <br />should become subject to the workere compensation provisions of Section 3700 of the Labor Code, l shall <br />forthwith eomply +Ar h thosa provisions. , <br />F..xplratlon Dato: signature <br />Printed Name: I <br />WARNING. FAILURE TO SECURE WORKERS' COAMPE..NSATION COVERAGE IS UNLAWFUL, AND SMALL SUBJECT <br />AN EMPLOYW TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE MNaR" THOUSAND ppLLARS <br />IN 36� ON ETO THE CM <br />I GGDE <br />Qp oMp aN, INTEREST, ATTORNEY'S FELS, AND DAMAGES A6 <br />ARDYI[IED FON IN <br />A ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(aignoWN MC -67 licensed uuthorked repr+rserrWiva), <br />Iwraby autbtrdxa (Print nanrb <br />to sign third San Joaquin GUuftty Wall Permit App1I=tlwn an MY behalf: I undomtand thle authorization is V«rtid for <br />one (t) year and Is Itmlted to the work plan dated on the front pipe Ot Oft 91010licatlan. <br />ERI) 34 -02 -OD 1 <br />sr=mol <br />