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JUL-24-00 TUE 1:15 PM M, D, E. <br />37)24/2000 10:13 2094671118 <br />FAX NO, 916 852 9535 <br />AGE STOCKTON <br />P. 2 <br />PAGE U3 <br />JA lattitO89:1505_5044,%2*-17-1 • Fitkottoot.... . <br />.,...:JyL.a.. <br />2303, .1 <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 #. 7z.01 Expiration Date: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />1 7 <br />SI -312 -=___-- ZOO I <br />Date e--1-/- 06 Contractor; fv/k_._ / bri ill' cn Y. co iv_ <br />4.- til d a gs <br />Title: f re.5 il <br />A.° N < liwir -7" Signature: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT <br />APPLY) <br />I have and wilt maintain a certificate of consent to self-nsure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />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: "S-EA- 1- C,64-1)e_fiSidid I%) Policy Number: 131' (t- (P-q <br />carrier and policy numbers are; <br />I <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 Gailtornis, and agree that if <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: 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.),114 ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />_rare. <br />• <br />Printed name: <br /> *WO./ <br />EiwArd 5e (C-57 license bolder), hereby <br />authorize .7Y1V /14;/AC ot 4411(e1 Geo,- 44 (consulting), to sign this San <br />Joaquin county Wail Permit APPlicatlon on my behalf. I understand this authorization Is valid for one (1) year <br />and is limited to the work plan dated on the front page of this application.