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�yr% <br />San Joaquin county EnvIronmenta t Health Department Una Iv well r" <br />JOB ADDRESS: 2.3+!0 Et15�. • Tfat PERNT <br />mit Application Supplement <br />SR#: ©5 ?3.5 <br />LICENSED CONTRACTORS DECLARATION LGD <br />hereby affirm th4t I am Il0en3ed under the provisions of chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my licence is in full force and effect. <br />Licenst : l g39(4S Expiration Date: <br />Date; •i I `� % Contractor. F SG" �Q1l.L 1 <br />SipnHture:., - Title: <br />Printed name: �t.d F�tSLN <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty Of perjury one of the following declarations: (CHECK CINE) <br />r workrs' <br />by Section 37and 100 Of the Labor Code for the performancel maintain a cettticaof consent ofof the �wo k foe which this petrmh s ssuad. ed for <br />_✓1 have and will maintain workers' compensation insurance, as required by Section 3700 of the tabor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and polity numbers are: <br />Carrier <br />PoNcy Numtser. <br />1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation laws of Calibc�rnis, and agree that if i <br />should become subject in the workers' cornpensetion provisions of Section 37 00 of the Labor Code• i shall <br />forthwith comply with those provisions. <br />Expiration Dater Signature: �r^��� <br />Printed Naha: ✓�V L J -LS C1 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION CPVP-RAGE IE UNLAWFUL, AND SHALL SUE:JECT <br />AN EMPLOYER TO CRIMINAL PEKALY1FS AMC CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />PROVIDED TION COMPENSATION, <br />INTEREST, ATTORNEY18 FEES, AND DAMAGES AS <br />FOROM 3'106 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />--Da1/ t. c)t F--t%e-�-44 (slgna)trre a 47licenaed authorized repmeaUtive)', <br />hereby zuthorize (print <br />to sign tittle San Janpuin County Weil Permit Application on my behalf. 1 understand this authorization is valid for <br />one (1) year and Is llrn ted to the work plan dated on the front page of this application, <br />EHD 29-0]^130: <br />622104 <br />£d Wd62:10 era@i' 61 ',AeW M86 B£8 6132 : 'ON 3NOH8 s i sfi l euy ouaZ puno.l0 : w083 <br />