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4".Omm'jm I Jeuu P. 2 <br /> 07/28/2003 10:39 209832' WRIGHT EFNIR WNTAL� PAGE 03/04 <br /> FIL-6= <br /> Sae Joaquin County Envtnor~tmenW Heatth Depertment unit IV Will Permit Applltotlon suppkm,int <br /> I JOE ADDRESS: 1411' - C4a9-TEz loA7r PERMIT sR#: 3 3 3� <br /> i _.� <br /> LICENSED CONTRACTORS DECLARATION QQW <br /> I haraby*Mrrn first I em licensed under the provisians of Chapter 9(corrrnendN vAth Section 7000)of wsian <br /> 3 Of the Suslness and Professions Code and my license is in full faros and effect. <br /> 1 <br /> License#: / ExWratian Clete �r�0 D <br /> Doss: �( CAnttaeter fU� . <br /> i — <br /> Signature: le: <br /> j <br /> Printed name: ` Q i�C� -�i�'�• <br /> I <br /> WORKERS'COMPENSATION DECLARATION <br /> I f hereby ARrm under penalty of pantry orve of the following dlWeraWns: (CHECK ONE) <br /> I{ I have and will snamtain a cutlficapt of c munt to solfJnsure for wakem,corrrpe efien,as provided fvr <br /> i' by SaWon 3700 Of the Labor Code,for sale pert manca of the work for whfoh this perrnh is Issued. <br /> have and will maintain workers'compensation Insurance,as required by Secdm 3100 of fm Labor(;;oft <br /> i for the performance ofthe w**for Mich feria permit is issued. *wnricers'empeassfionilmourance <br /> caviar and poky nCurnbers are: <br /> Carrier c) Policy Number. (� _ <br /> I cen3fy that in thct Per"Ince of the work for which Inas permit is issued,I shsk not employ any pers'A in <br /> any manner 3c as to bewme3 Subject to the workers'come oration taws of Celifemia,and egree hist.T I <br /> should become subjw:t tt:the worken'compen3a' ieiana of SWen 3700 of the tabor Code,I RhWi <br /> i forthwith complywilh those provisions. <br /> 1 Dom. Signaturo: ` <br /> Printed Name: <br /> WARMUM.FAILURE TO SECURE WCM?MRV tat3iMF2NSATtON COVIRACE IS UNLAWFUL,AND SHALL SUE-JECT <br /> AN aNPLOYER TO C11"MINAL PENALTIES AND CIVIL FINES UP M oma mUNDM THOUSAND DOLLAA3 <br /> 4t71}.OA4 J,IN ADOPTION TO THE COST OF COIL IMAT1Off,INTUM,ATTORNEY FEES.AND DAMAGE1,AS <br /> PROVIDED FOR IN SECT M ane of THE LAMM CODE. <br /> AUTHORIZATION FOR 07WERTHAN C-57 SIGNING PERMIT APPLICATION <br /> �I (ren W-W liken mW auUmized represemittwl, <br /> henby authortta gwint aamwWRt G h�r ON 1E.cIT/¢L SSV/tF.S .iMt. —�l CFr"-L rnx[S <br /> to sign this San Joaquin CavrMy V%U Permit Appltcatlan on my osnaif. r understand thea autCterfiagon is vrtlF I for <br /> Ona 11)yasr and Is:united 6s the wont plan dated an the tmnt page of this"pucatlan. <br /> 8�21 IUl <br />