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Of/* $ .48 FAX 510 6141 GEOATRIX OA ` <br /> BL D <br /> 014 <br /> I <br /> Y <br /> ccatiort suPPletriMt <br /> San Joaquin County F0yiraunent3l Health Department Unit N WdllPeMit <br /> PERMIT SR#: 1 <br /> JOB gpDRESS: Q Lc <br /> LICENSED CONTRACTORS DECLARAT10N �© <br /> erRb $Efate That i am ilrLhSed undar the provision?of Chapter 9(Commencing with Sedon 7000)07 C7ivision <br /> i h Y I;cansa is in full rorce and ntfact, <br /> 3 of the Business and Prot'ossinns Code and my f <br /> t� ar-y� Expir�tlon Date: <br /> License�:GS7. -- r <br /> Cantrae.tor: <br /> Date: <br /> Sipnaturo <br /> printed name:_,irL n 1 <br /> WORKERS' COMPENSA-nm DECLARATION <br /> t hereby ofri+Trr antler penalty of perjury 0116 of the following declarations: (CHECK ONE) <br /> I have and will maintain a Certlfical ,of cannent to sclf•insure for workers'cfxnpensation,as provided for <br /> —'by Section 3700 of the Labor Code,for the performance of the work for which Ole permit is i"ued, <br /> enseikXt insurance,as requtmd by Section 3700 of the Labor Code, <br /> have and will maintain workers'camp <br /> My Workora, ..penssum insurance <br /> for the perf4rmanoe of the work for Which this permit i5 Issued. <br /> carrier and pdicy nurnters are: Q, <br /> taailcy Nurnher. �_�— <br /> Carrier: an person In <br /> Ce6fomla, and agree that if I <br /> { certify►rat In the performance of the work for which this Peiat� Issued,ontrKs shall hat*rnPlnY Y <br /> ertsation�jrpVt�ivn,at Section 3700 of the Labor Coda,1 SttiBll <br /> any msnnor to as l,o become Subject to the worwe compens <br /> should became sUbOct to the ,Gump <br /> forthwith Comply with those provisions <br /> Signature: <br /> Date; , <br /> Printed Nama: <br /> t]CIVIL FINE3 UP T�oHr-tiUND�T+�'''NA D DAMA <br /> WARNING:FAfLURE Y seGtlfiE WoIIKERs'CaMPEN$ATION COVP-RAGE M UN1JplVFt$ ANO iOL LIL SUBJECT <br /> AN gly{PLt�YFA TO CRIMINAL PENALTIES AN <br /> INTEREST,A�p�1EY'SS,AND GANAClE9 AS <br /> (pROYioEO OR FOR 5e,TION los d THE LABOR COLE. <br /> TIOhI FOR DTH R 7HAN C-57 SIGNING PfRMiT ApPLlGATION ' <br /> AUTHaR1Z� o rassntettval, <br /> gnaw,x,37 t►wtu.d.ult► rued r+pr <br /> MIL <br /> hereby authcrtz*(print nsma) nd thW suthorization is valid for <br /> to iiQn th10 sen Joss oln county W&II Permit AppllcaUon on my bQhetr. 1 und.rau <br /> one(1)y end fa Iimtbd m the work pian doted on tho front p+9*of this a 1°n• <br /> e-zsof t M1 <br /> Qyl IKVO X17i3dR099 Ttit ego OTS xvi 1Z:60 311E COIt?ZfBo <br /> ZOolz ❑pZE 13rN3SU-1 dH WHbb :E BOOZ 9;? qnd <br /> z 'cl <br />