Laserfiche WebLink
@712B/20a3 10:39 2098325'- - - p.2 <br /> i IJRIG6�T EtNIRL>1 tJTALit PAGE 03/04 <br /> FiLrz <br /> San"aqua!County Emrtra manW Hrafth D <br /> +psrbrent Emit IV Watt Parrish AppIcadan 48upplom,: nt <br /> i JOB ADDRESS: 14 14' r- . C4.4 F-TE/Z. Why ' <br /> PERMIT SRV. <br /> 5 (�- <br /> LICENSED CONTRACTORS DECLARATION QW <br /> I hfrsby arm that t am Itcensed under ft provis na of Chapter 9(coni anc ing with Section noo)of Wsion <br /> 3 of Ow 80alness and Professions Code and my license to in hili forty and affect. <br /> License# M r=,VratanDaNK <br /> Dau: "7( 0 � <br /> Contractc r f <br /> i — <br /> Signature: <br /> Printed name: (V f[1t' 4-74--f <br /> WORKERS'COMPENSATION DECLARATION <br /> f hereby affirm cinder penalty at perjury one of the following dedomtiens. (CHECK DN!~) <br /> have and will fnwntain a Cutilicatb of omsent to sail-4naum for wormers'cmmpereadon,as provided m <br /> I by Section 370[1 of the Labor Cade.far Vie perforrnar�ra of V'srrerk fpr which fftfs Deans is issued. <br /> NZ tsays and will rt intsin workers'Carrpensadon insurance,as rsqui,-PA b Sectlan 3700 of the r Cl <br /> i for the petforrnance of the work for which this permit is issued. My workers'com Labor ode, <br /> f catriar and poilcy numbers ere: n trerts6ti0n irlaUrdnLa <br /> Carrier, cS 7 Policy Number. CP <br /> I i cantly that in&a perWTance Cf the work Tor wfticSt this permit is iwuect I shall not employ any oem';n in <br /> any manner ao as M became subject to the wookers'compensation taws of Calbfamia,and•9raa that.Y I <br /> should became subject to:he workers'comPen3a' vieio^ta of Seclfon 3700 0{the labor Code.I t heq <br /> forthwith Comply with Boase provisions. <br /> Date; Signature. <br /> Printed Name: <br /> WARNING:FAILLiRE TO SECURE WORKERRV cOMpfNSA71ON COVERAGE is UNLAWFUL,AND SHALL SUE JECT <br /> AN EMPLOYER TO C911MINAL PENALTIES AND CML FINES UP TO ONE HUNDRIM THOUSAND DOLLARS <br /> rS1DO.Q00.j,IN ADOMON TO THE COST OF CDIIIPEJVSATfC114 IW MRLV,ATTORNEY'S FEES,AND DAMAGE:4 AS <br /> i ROVIVED FM JN sec-now 7796 OF 714E LMNi R CooE. <br /> AUTHORIZATION FOR OrMERTHAN C-67 SIGNING PERMIT APPLICATION <br /> If <br /> (trt�tesvre ofCSJ Hnresed wkfiodaad rapra+ssrtt.ydvi), <br /> het�y autMrine(prlrst nameL�VR t G WT EA)y r"4WAt 7-4 _540-VrCeS .I,uc. <br /> to sign this San Joaquin County Mu PertnH APpiitaelan on my Oedtisfr. I undaratznd this acRhor=160"is v0 I for <br /> era(1)beer and w Arriitod to the work pian dated an tfre front page a!tNA apptieation, <br /> d 2?-02!1Mi <br />