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p.11 <br />-',FliOrit <br />4.0trin a • F . • - nr.id <br /> Title: <br />_Zcertify that In tho performance of the work for which this permit is Issued, I shall not employ any p;vson In <br />any manner so as to become subject to the workers' compensation laws of Cellfornia, and ewes ti• n 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 />Dots! tce• 13 .9t ignature: <br />Printed Name; <br />WARNING; FAiLuRE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUINECT <br />AN EMPLOYER To cram INAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(S1Dtl,000.), IN ADDITION TO THis COST OF COMPSNSATION, IN-WIEST, ATTORNEY'S PEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION aTos OF THE LASOR COD <br />Chr 4r Ce(t 12 .-' llooruied authorized monism mtlive), heezby <br />authorize , A's:11,4 2 ce,,,,,totc. ,,e) 617-1c4- <br />to In this San JosqUin County Permit Applicoti on on my behalf, I understand this authorization is vslid for <br />one (1) year and it limited to the work plan doted on the front pair of this application, <br />5.171400 I MI <br />JA1110190 <br />P. Z/E <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />i hereby affirm that! am licensed under the provision* of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business end Professions Code anti my license Is in full force and effect, <br />License C cic-3 ktel Expiration Date: <br />Date: I ' <br />Contractor; <br />or .,/,./jr/,, <br />signature; <br />Printed <br />WORKERS' COMPENSATION DECLARATION <br />I hereby effirm under penalty of perjury one of the foilowing declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self-Insure for workers compensation, as provIded for by <br />iection 3700 of the Labor Code, for the performance of the work for which this permit it Issued, <br />/I have and will rriatriteln workers' compensation insurance, eie required by SsatIon 3700 of the Labor Cods, <br />for the porforrneno, if The work for which this parmX Is Issued, My worimsral compensation Insurance <br />carrlsr end policy ,oers are: <br />Cimier Poly Number: <br />,