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- � 004 <br />San Joaquin County Environme tal Health De rli\� i Permit Application Supplement <br />JOB ADDRESS: Nw /�v�.- PERMIT SR#: OD ��O <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and effect. <br />License #: V/ .276 Expiration Date: <br />Date: 12f9�a 3 Contractor:/Q e1;,ei� ii�Su��u,.r7�1 <br />Signature: <br />Printed name: <br />Title: � u �ncs�'c-Icn-� <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />t -"'I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: SA cA C )mP lc S • INA Policy Number: 1 D S4: i i - p3' <br />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 California, and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: <br />(� <br />Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INT€REST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C:57 -SIGNING PERMIT APPLICATION <br />I, <br />hereby author zi e"(pnnYr'tiaM*) <br />to sign this San Joaquin County <br />one (1) year and is limited <br />8-29-02 / MI <br />signature ofC-57 licensed authorized representative), <br />Permit Application on my behalf. I understand this authorization is valid for <br />work plan dated on the front page of this application. <br />