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"� •av 05 : 14 PM ENppog <br /> • 416580��30 <br /> • P_ 02 <br /> 04;02/200q 16:35 FAX 209 9480621 <br /> Z002/002 <br /> San Joaquin Cntmty,E�"t��nmenlal 1-laclth Sor icco ` <br /> / �t Untt IV Wall Yermit Application SV <br /> JOBADDRESS. ' PPlement <br /> ---___ PERMIT <br /> LICENSED CONTFZACTORS nFrl q►anT►of► <br /> (►_Cb) <br /> ed <br /> I hereby affirm that I am licensed under the <br /> 3 of the Huoinesy and ProfessCad provisions of Chapter 9 co <br /> �'y�j e and my license is in full farce Lana e�1np with S90ttoyl, n 7000) of 0ivlsion <br /> Licerlsq#;nate_ Expiration Oat.: <br /> —� COntrBCIor- --t <br /> . <br /> Signature; <br /> Printedn3rno: <br /> WORKERS' CO <br /> MPENSATION DECLARATION <br /> hereby aftirm under penalty ofer'u <br /> p 1 ry one of the following declarations: (CHECK ALL THAT APPLY) <br /> -Xhave and will maintain a Cea'FlOiata of consent to self-insure for Worker <br /> Section 3700 of the Labor Code, for the performance of t <br /> kers' compParmlp0, as provided for b <br /> ha work for which this, permit is issued. y <br /> I have and will maintain workers'compensation Insurance, as required b <br /> for the performance of the work for which this permit carrier and policy umbers are: p mit is issued. My workers,Section 3700 of the Labor Code, <br /> S compensation inpUrance <br /> Carrier: <br /> POIlcY Number. 7`3 <br /> I certify that in the r—,F � — �1.� <br /> auy manner r^c^oo of th0 wwh fui wJJlt-h pr,ls parrn,t(a i33UGd, I s <br /> should be So as to become Suhjarl t0 the workers' <br /> Dome sub com ht+il hat employ any person in <br /> forthwith c )eCt [0 the workers'COm en Psions un laws of CaiflOrnie and Agrbe 91af if I <br /> --�' wi those provisions. p sation provisions of laws <br /> 3700 of the Labor Code,ode, 1 shall <br /> Date: � <br /> Signature: <br /> Printer{ Name.- <br /> WARNING' <br /> ame:WARNING' FAILURE TO SECURE WORKERS- COh1PEf � _ <br /> AN EMPLOYER TO CRIh1SEC PENALTIES COVERAGE IS <br /> (51110,000.), IN ADDITION TOT COST OF COM pIi NSATIDNUP TO ONE T REST HUNb UNLAWFUL,ANp SHALL SUBJECT <br /> PROVIDED F IN SECT O RED 7HOUSgNb DOLLARS <br /> N 3706 OF THE LABOR COPE. ' ATTORNEY'S FEES,AND DAMAGES AS <br /> I, <br /> avthoyyE_ (C-571ie&n5ed aVthorizsd representativty <br /> hereby <br /> to sign this San Joaquin County Weil Permit Application on m <br /> one (1)year and is y behalf. I understand this authorization Is valid for <br /> _ _ 20g0/ <br /> $ 1T MI Ilmited to tho work plan datod on the front gaga of this application. <br />