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07/2912083 30:39 2@9332 I' AI PAGE 03/04 <br /> F1 L <br /> + _Y <br /> sen Joaquin Courcy I" citit tenW Health Depsrtrnant ynit`NUWII par-MR AppNcsttonSupplorrnlnt <br /> JOB ADDRESS: I,{ 1 C4-4R-Tgfz.. V)hI/; 'PERMIT SR$: �4- <br /> I ' <br /> LICENSED CONTRACTORS DECLARAMNN ) <br /> I h*rsby aRrm that 1 am licensed under the pravislons of Chapter 9(com nendr g with Section 7000)of s5i-,rislen <br /> 3 of"0uslnesrs-an-d Professions Cade and my Iloense is in W fom wd effect. <br /> License# .� �!? -7 Expiration 'Date: <br /> Data: I 0 Contractcr'_ ;E {� tfr- <br /> I- <br /> i 7 h — <br /> Signature• le• <br /> i Printed t►arna: t� CE <br /> Pr�4 <br /> WORKERS'COMPENSAMON DECLARATION <br /> f hereby affirm under penalty of perjury one of the fallowing decieratiens: (CHECK ONE) <br /> I have and will maintain a coalf+cea cf cionsent to saif4ns'urs for workers'compensation,as provided for <br /> i by Section 3700 of the Labor Cade,for ie pertrmarme of,the 1Mvk for wh18h this permit is Issued. <br /> s <br /> 1have and will rrlarintsin wc*arz'=npensalion insurance,as required by 134ction 3700 a the Labor Code. <br /> for the pertor Trance of the work for wNch tt -'permit is issued- W vooekers'! 'peneadon insurance <br /> carrier and poky numbers ore: <br /> s j <br /> � Carrier. <br /> cs 1'Y? Policy Number._ 3 <br /> I certify that in ttto perr<xrnance cf the wpnc for which this permit is issued,I SW not employ any vers m In <br /> I any manner ac as to be=e subject to the workerV compene4on tam of California,and agree that.f I <br /> should became subject'c fhe workers'ccrnpensa inions of Se0am 3700 of t'»labor Code,I shall i <br /> t forthwith amply with those provisions. <br /> Date; .Sipatura: I ' l <br /> Printed Nam is ULJ i, <br /> WARMNG:FAILXRE TO SECURE WOItPW Ii'COIMPEI4SAT10NC.OVERAGE IS UNLIAVJFUL,AND SHALL SUE JECT <br /> AN Ii MpL41'Ht TO C91MINAL PENALTtE8 ARID CIVIL 11NES UP TO ONE HLIlfOilFD T}IpUSAND COLLARS <br /> ?5170.Q41i.1,IN ADOITION TO THE COST OF CCWPEMAT10K INT'kM#,ATTORNtM FEES,AND WWAGE°i Az <br /> PROVIDED FOR IN SECTION 7ME OF THE LA*M COOS.. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPUCATION ' - <br /> F, I, (s r7wrf ow-P tice6w authorized repmern tthm), <br /> rtvrs8y atrtJtarlre(print Hamel v+1Ri G hF T N r �1,HB.+IT11-L�f$V1CIF5 <br /> .. i' <br /> to si9ro this San Joaquin Caunty V%1l Permit Appaaatlan on my beirlaif. I undarstard this■uelosl"W"Is valM I far <br /> one li)yew mod is urrdted to tr,•work plan dated on tha horst Pigs 91.ti6s agPpcatisan <br /> 10 <br /> F <br /> t <br />