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JAN -14-00 FRI 09:34 7078648886 P.02 San Joaquin County Environmental Health Services, Unit I'V., fe14 Permit ApOcatlon Supplement DD z�sLB' LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of DiviS,or 3 of the Business and professions Code and my license is in full force and effect, LlCense #: C 57 ` Expiration Date: 9L la '? Iol-o 21 _ - Date:—1 f Contractor: AM r,,A ora i oh, �tc X& signature Title:O a'HYti1I /f�Glhuc ep _- Printed name: J C cN iT t"rC!q ! E ---------- WORKERS' COMPENSATION DECLARATION t -areby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) t have and will maintain a certificate of consent to self -insure for workers' compensation. as provided for by Section 3700 of the Labor Code, for the performance of the worst for which this permit is issued. r 1 have and wilt maintain workers' compensation insurance, as required by Section 3700 of the labor Code. for the performance of the work for which this permit is Issued. My workers' compensation insurance carrier and policy numbers are - Carrier: M tt �'► a f` Policy Number. / 616 4' 6 6 — -19 -- _� i certify that in the performance of the work for which this permit is issued, I shall riot employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if 1 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. t shall forthwith comply with those provisions. kl° Date: -- IA 00 _ Slgnatur ?& <<---------- Printed Name: ^ J C e _ZT_ � r TG tu 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 ($100,000.), IN ADDITION TO THE COST OF CNOSDATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR N SECTION 6 OF THE LAB { I SCo� FT'iz#fDE (C-57 Ilcensed autnorized representative), hereby authorize d b Pn'� Dat4 L_. OI- 1_0y�VOLS- -- ---- Y - to sign tills San Joaquin County Weil Permit Applkatlon on my behalf_ I undersWd this authorization is valid for one (1) year and is limited to the work pian dated on the front page of this application.