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i <br /> 1 <br /> 1 <br /> 7Sanjoaquin <br /> County Environmental Ftaalth Departmorrt nit N Wall Permit Application Supplemu It*SS: 03 e PERMIT SRIF.._ D 7 <br /> LICENSED CONTRACTORS D CL ARATION (LaR] '. <br /> 1 hereby affirm that I am licensed under the Provisions Of Ch2P Of 9(Cnmmer>Cing Matti Section 7000)of Diusion <br /> 3 of the Musiners and Prafessions Code and my license is in f it forW and effect <br /> Li60hse ESgriratlt]n ate: <br /> Date, T-4 O Contractor - <br /> /q rift¢- <br /> Signature: /� - <br /> Pointed nam � Ze: F � 7 _ I <br /> WORKS W COMPENSATI N DECLARATION <br /> I hertby affirm under penalty of pOvey one of the following d cJarnitiam: (CHECK ONE) <br /> I have and wm maintain a certif=te of consent to welf-Insure for wort<ers'carrsps+nSatiart,2s Provided'or <br /> by Section 3744 of Me tabor Code,for the perfbarianct&the work for which hi I permit Is Issued. <br /> I have and will mair"in workers'eampensation insurance,as requirled by Sea3O l 3700 of tree tabor C Ode, <br /> for the performance of the work for which tfti3 permit Is i ued. My woftrV Ctlmpensation irmuratnw <br /> Carrier and policy numbers are: <br /> Carrier, F r ;�k6+ Policy Number:JmL(1.�)Q <br /> I certify that in the perfonavance of the work for which this permit is issued, I sh all not Employ any persc n_ In <br /> any manner so as to become subject to the workers'compensation laws of Ca litramia,and agree that i" I <br /> should become&object to the workeW compensation provisions of Section 3730 of the tabor Code,]!;hall <br /> forthwith comply with those provisiona. j <br /> Expiration Date- Signature: _. M <br /> Frihttd NOrri9' �- <br /> WA)RNrNG:PArLURE TO SECURE WORKERS'COWENSATION COVERAGE IS UNLAM-UL,AND,6MALL SUI§,1ECT <br /> AN 04PLOY'ER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HLNDIW I)THOUSAND DOLLARS <br /> (5144,444.),IN A150l' ON TO THE COST OF COMPFMATION,IWE ESI",ATl'ORWIlf'S FEES,AND DAMAGES AS <br /> PR0%nDED FOit IN SECrOM 3746 OF THE LABOR COOI!, <br /> AUTHp-J I,ZATIIOl/ON TFOR Or/T/HER�pTHAN CZ7 SIGNING PERMITAP'PEICATION <br /> 1,� {�f {Cl ;1 1�t[C.�j e f I iN l "sgnature&C-67 ita*nsod wth rlud reprozenta thm). <br /> t <br /> hereby au"a"Ze(print name) fIrene ( gr67LNwz <br /> to sign this Sen Joaquin County WON Permit Application on mV behalf. I undonrtand ihts authortaatlan is valid for <br /> one(9)year and it Invited to the work plan demo¢on tho front p agip of thio apptieatton. <br /> S-2242 r Ml <br /> SIiD 29.01-04I <br /> I <br />