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II :4UAlfl; 4C,58773 = 209 838 9883; #2!2 <br /> JOB ADDRESS:-/8'0 I VV, 0 PERMIT SR#., Ao F// <br /> LICENSED CONTRACTORS DECLARATION (LCE)) <br /> I hereby affirm that I <br /> 3 of the Business an,licenseti under the provisions o,, Cha ter <br /> ness an <br /> 9 commencing Will, Section 7000d Professions Code) and my fic,-,nSe is iri fulf force and effect, <br /> License#: Expiration Date. —2V3 <br /> Date: <br /> Contractor: VIP 0 t-- <br /> Signature: Title: Area <br /> Printed narna; <br /> n <br /> .......... <br /> WORKERS' COMPENSATION DECLARATION <br /> I her,",al"1111i under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to setr,,in%kire for workers'compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> 1 have and wilt maintain workers'X.- 0orripensation insurance, as required by Section 3700 of the Laf;ui Code, <br /> for the performance of this work for wnicti this permit is issued. My workers'compensation insuriince <br /> carrier and policy numbers are. <br /> Carrier; <br /> Policy Numbet: WLS-N-772-58--A <br /> -x— I certify that in the Performance of the work for which this permit is issued, I shall 110t (,'#Tlploy any pe-spg, <br /> any manner so as to become subject to the workers'compeizia tion laws of California. and agree that ,f I <br /> Should become subject to the workers' I)Perl tion provisions of Section 3700 of the li-,abor Code, I shall <br /> forthwith cr)n1ply with those provisions, <br /> Date: /6/43/99 Signature: <br /> Printed Naine: Kieik4lder <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION C /ERAGE IS UNLAWFUL,ANP SHALL SU13JECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000,),IN ADDITION TO THE COST OF COMPENSATION,INTEREST, ATTORNEY'S FEES,AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I. dim Kiel.n.ro-lAtir ref <br /> authori2o &e.� 40f Gat VI <br /> ca <br /> (Consulting),to Sign this Sari <br /> Joaquirt County Weil Permit Application on my behalf. I understand this authorization is va"d for one(1)year <br /> and is limited to the work plan dated on the front page of this appijcatiom <br /> ............ ........ <br /> ................... <br />