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i <br />02/22/2005 10:43 91686116"a0 5ECOR PAGE 02/02 <br />C <br />0- <br />69 C 7�� ZT7iS <br />San Joaquin County Enyvironmental Health Department Unit IV Welf Permit Appllcatlon Su I men <br />e3 G�A IK Rm-trj,l-aPt ypv�" ���� T �� <br />JOB ADDRESS:/ 2�33Cos.tr.c�tir,,. PERMIT $R# <br />(� <br />7-7P.5'4 o wK .Y L % ill"d CJCJ T L t!/ L <br />LICENSED CONTRACTORS DECLARATION(!,CD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (cornmencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and effect. <br />License #: C..` 7 C� � Expiration <br />7Date: / / / /G► �' <br />Deter 2/ Contractor. F�'i f�%/i-•' !. 7Y,ifri� <br />Signature: Title Q"fZ 7410A <br />Printed names _„ r T_ _ z►�1"- /'Hn ��'"' <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 certifioete 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 thls permit is issued. <br />I have and will mainmin workers;' compensation insurance, as required by Section 3700 of the Labor Gode, <br />for the performance of the work fvr which this permit is issued. My workers' compensation insurance <br />carrier and policy n/ -umbers are, <br />Carrier: Sear, Policy Number: 46 /01k a a6( <br />I 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 cf California, and agree that if I <br />should become subject to the workers' compensation provisions of Sectlon 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: — ignature: <br />�I O�rinted Name: --- <br />AA <br />d oK- <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION CCVI~RAGE 1S UNLAWFUL, AND SHALL SUBJEGT <br />AN EMPLOYER TO CRIMINAL PENALTIES ANO CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAOE8 AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1,abt „ (signature ofC•57 licensed authorized representative), <br />hereby authorize (print name) �0.rtiQ+�, r��� 01� 56EC- <br />to sign this San Joaquin county Wel) PermitAppllration on my behalf. 1 understand this authorization b valid fvr <br />one (1 ) year and Is limited to the work plan dated on the front page of this application. <br />8-2"2f MI <br />CHD 29.02,"^: <br />6/22,0 <br />ZO �19vd 9NI11ILIQ 903x9 �_OEOETCSZG 005:121T OOOZ/ZZ/ZO <br />