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Jul 07 04 09:54a . SlG ?-9558 P. 1 <br /> 97/07/2004 06;44 2094. , 18 ;., A STOCKTON PAGE 02/02 <br /> I <br /> 3 <br /> San Joagaan Country EnviTonmental Fiiiialth lWipgritinent unit V Well PamitApplicAion Supplement <br /> JOB ADDRESS:_J013 r,6"fW tx3 ERMrr SFC . ; <br /> LICENSED CONTRACTORS DEC RATION (-L1:D) <br /> I <br /> hereby arm that I arrl IieerisW unser the provision.;of Chapter g eemmencin with tior 7000)of Divisit n <br /> 3 of the Suainess~a7nd Prroofessions Code and my fican5e is in full fa and C— <br /> license ExpirationData � �f` <br /> Dale: Co -tor, A /� V, 0 <br /> F <br /> Signature: raw de <br /> Printrad name: <br /> i <br /> WORKERS'COMFENSAMN DECLARATION <br /> I hereby affirm under penalty of perjury one of tho following decia ions: (CHECK ONIE) <br /> I have anti will maintain a Certificate of CWserd to self4fisure t workers'cvmpenwMan,as provided for <br /> tfy Section 3700 of the labor Code, for to performance ofthework for whic.h this wylnit is issued. <br /> 1 Have and will maintain worke&compensation irrsuraoft,a'.mquired by Section 3i'00 of tho L-bor Cudr <br /> fpr the performarsce of the work for which this pormit i5 issued. My workers'compensaWn insurarme <br /> carrier and policy numbers M <br /> Carrier. Oi'v► olicy{hum ' �- <br /> -- - <br /> I certify that in the performa nco of thn w®rk fnr which this perm" Is issued.1 shall not amply any person ii i I <br /> any manner so as to become subject to the workers'compen ion lava of CalffOmin:, and agree that if f I <br /> should become subject to the workers'compensation provisions of SeGtion 3700 Of fhe Labor Cada, I shat I <br /> fodhwilh Comply tiavtth those prov1ex'MS. <br /> Expiration Date' Signstt": <br /> Printed Name: <br /> WARNING;FAILURE TO 5cauRE wt7rtKERs'cOMP"SATION COVERAGE 15 UNLAWFUL, AND SHALL SUBJEC T <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINE$IJP TO 001 P HUNDRED THOIJ&kNO DOLLARS <br /> (S10111,000_� IN A001TION TO THE COST OF COMPENSATION.INTER 7,ATTORNers FEES.AND DAMAGES AS <br /> PRCMDW FOR iN 5CCTM 3706 OF THE LAMM COW- <br /> AUTHO IZATION FOR OTHER THAN C-V SIG IING P'RM T APPLICATION <br /> signstu aM.87 licsnayd outhorime0 resenbi" <br /> herwhy (print na"Ve <br /> to sign this Seen Joaquin County Wall Permit Apptieathm on my behalf, I understand this auttltorbuitldn Is valid,for <br /> ant,(1)year and Is limited to the work plan dozed an cher front.page M I his appllestlon. <br /> 6.19.82 J AMI <br /> 1StiD 2SM2-Oi33 <br /> 9J311�IIQD2 <br /> i <br />