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i- X002 San .loaquin County 1`nviro��rnentlat Healtfi, Services, (�n1t.IV litrell Permik Ap�licatC�/ent JOB ADDRESS: PERMIT' SFS#: T 0 v 39 LICENSED CONTRACTORS DECLARATION (l,CD) 1 hereby affirm that I dpi licensed finder the provisions of Chapter J (comrnencing with Section 7004) of Division 3 of the Business and Professions code and my license is in tuli force and effect. 1 j License `: oioy _ Expiration Date: Date: — - Title: - -- Signature: Printed name:0d ► �' – 1 WORKERS' c0MPi=NSATION DECLARATION I heroby affirm under penalty of perjory one of the following declarations: (CHECK ALL THAT APPLY) I have Section nd will3700 ai Labor Codfc for the performanceicate of consent to of i c work for which this permits is issued-lnsure for workers'compensatiort, as vided for by v I Have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, �T for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: _ Carrier: C ,( Policy Number: _ I certiy that in the performance of the work for which this permit is issued, I shalt not employ any person in any mariner so as to become subicAct to t}Ie worker=' cAmpensation laws of California, and agrees that it) nsation provisions of tion 3700 of the Labor (rode. I shall should become suojectto the workers' comps P S fortnwith comply with those provisions. Date: 13 I �`'' Signature: Printed Name: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT , AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS IN ADDITION TO THE COST Or COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 Or- THS LABOR CODE. C(C-57 •'�n-�ed-authorized repressntRtive), hereby W/� autharige i , W– to sign this San Joas�uin CounWell Permit Application on my behalf. i understand this avfihorization i9 valid fos one (1),r and is Iimitad to the work plan datetl an the front page of this application. _..