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Contractor: Date. ) <br />Signature: <br />Printed name: <br />r Paq (JAL 4.1/ <br />a II 0 III PIA <br />IF 11 , <br />()V / 60(1 Title: <br />(41feirz_. <br />1 r5 j ti <br />I-1 of <br />0 <br />San entai Health ServIcari, Unit IV Wail' Permit Application SUpplement <br />JOE ADR$ PERMfT SFM Pd24 <br />5t c)t— <br />UCSED CON-TRACTORS DECLARATION (LCD) <br />hereby affirm that I am lieznSed under the provisions of Chapter- 9 (c.ommencing with Section 7000) of Division <br />S of the Eusiness and Professions Code and my license is in full force and affect_ <br />License It: LI 51 Expiration Data: /d/b/ /0 -; <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the following 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 />Section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. <br />/ 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 and policy numbers are: <br /> <br />Carrier: Mita- Policy Number: 1/1--) D <br />I certify that in the performance of the work for which- this permit is issued, I shalt not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if! <br />should became subject to the workers' compensation provisions of Section 3700 a the Labor Code, I snail <br />forthwith comply with those provision. <br /> <br />1-0-/ 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 PINES UP TO oNE HUNDRED THOUSAND DOLLARS <br />(S100,000), IN ADDITION TO THE COST OF COMPENSATION. INTEREST, ATTORNEYS FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br />Date: <br />ary ett_ <br />Ans vit-eixe authariza <br />(C-57 licensed authorized repressntathre), hereby <br />17)K <br />to sign this San Joaquin County Weil Permit Application an my behalf. I understand this authorization is valid for <br />one (I) year and is limited to the. work plan. dated on the front page of thie application. <br />S-17-2000 / MI <br />•