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authertm <br />AIM al CIO <br />San Josqui <br />JOB ADDRESS: /6.2-5 Ai. <br />ent Health Services Unit IV ell Permi 7 Application Surpierneint <br />c-.4-sC PERMIT SR* <br />ja <br />00 N 7 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby fflnii that l am licensed under the provisions of Chapter 9 (commeneng with Section 7000) of Division <br />3 of the Elusiness and Professions Coda aid my license Is in full farce and effect. <br />e: 1,0(310 -2' License #: 1-5-to 407 Expiration Dat 1 <br />t-s Date: /5-, (:)\ ---Th/ Contractor a J S1 <br />Signature: /-1/C4‘71 j fi <br />rn <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penally of penury one of the following declarations: (CHECK ALL THAT APPLY) <br />I ha:ie and will maintain a ceilificate of consent to self-Insure for workers' compensation, as provided for.* <br />Section 3740 of the Labor Cote, for the performance of the work for which this permii is issued. <br />I 1 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 />Rio62_,(- Policy Number: W C CO rio 0 <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 se as to become subject to the workers compensation laws Of C.aliftmla, and agree that if I <br />should become ztihject to the workers' compensation provisions of Section 3700 of the Labor Cade, I shaft <br />forthwith comply with those provisions. <br />Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND MIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION nos OF THE LABOR CODE. <br />to sign this San Joaquin County Wall Pannit Appil ion an my behalf. I understand this autheriaattion is valid for <br />one (1) year and Is limited to ths work pion cfotad on this front pose of this appfloatIon. <br />5-17-2.tX10 I MI <br />Printed name: <br />Carrier: <br />Data: <br />(C-57 licensed authorized representative). hereby • <br />6-3-(s ellvikow