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SENT BY: SPECTRUM; 2- 1 B:11AM; 4658773 => 20946B3433; #2/2 <br /> San Josiuin County Environmental Heaith Serwce,t, Unit fV We.Petm......... --- -... <br /> �����',, It it Application S/upplement <br /> JOB �ADURESS: J .,.(�f!r �A_ PERMIT SRM05681 5681 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Saction 7000)of Division <br /> 3 of the Business and Professions Code and my license is in Lull force and effecl. <br /> License#:�S /a.?y�,�' Expiration Date: ._ O/ <br /> Date. Contracto <br /> Signature: -_ __ <br /> _ Title:Q���Q1Cj�T <br /> Printed name: — <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm uruler penalty of perjury one of the following declarations. (CHECK ALL THAT APPI Y) <br /> I have and will maintain a certificate of consent to self insure for workers'compensation,as provided for by <br /> v Section 3700 of the Lobo(Code, for the performance of the work for which this permit is issued. <br /> _I have and will rnainlain workr:rs'compensation insurance, as required by Secborr 37GO of the Labor Cotte, <br /> for the performance of the work for which this permit is issued. My workers'Compensation insurance <br /> carrier and policy numbers are, <br /> Carrier: dr(� F'ofic Number, <br /> ./ .__ v - <br /> I certify that in the performance of thlo work for which this permil is is3ued, I shelf not employ any person in <br /> any manner so as to become subject to the workers'compensation taws of California, and agree that if I <br /> should bacorne subject to the workers' compensation provision s of Section 3700 of the Labor Code. 1 shall <br /> forthwith comply with those provisions <br /> Date: ....✓ �5r_(. ._....m- _Signature: .. �_._.-.. — <br /> Printed Name: I <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION VERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP ONE,HUNDRED THOUSAND DOLLARS <br /> (Stoo,000),IN ADDITION TO THE COST OF GOMPENSA-CION,INTEREST,ATTORNEY'S FEES.AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 OF'CHL LABOR CODE. <br /> r ,,_(C-57 licensed authorized represontstive),hereby <br /> f <br /> 1�r <br /> authorize w., _ C �+� /l carr�• <br /> 1 Joaquin Count WQII Permit Application on m behalf. I understand this authwlxatioa valid for j <br /> to sign this Sun Joagi y App y <br /> r <br /> one 01 year and is Ilmitod to the work plan datod on the front papa of this application. <br /> 5.17-20001 MI <br />