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PAGE 03 <br /> 08:21 2094683433 .FIFTH FLOOR • <br /> _ �leirieflL'•'_ - <br /> aquili Cr ultty. nviroomental:HealtkS®tykes,Unit IV We11 Permit AppFgca ^ <br /> 7R�SSm <br /> #1. !0J <br /> .c. <br /> LICENSED CONTRACTORS DECLARATION (�} ofpivlsion <br /> arm that 1 am licensed under the provisions of Chapter 0 (commencing with Secticn 7" <br />,isiness and Professions Code and my license is in full force and effect. s— <br /> _C,r 1) - Expiration Date: �-.— <br /> Contractor: <br /> r <br /> WORKERS' COMPENSATION DECLARATION `n <br /> fF.rm under penalty of perjury one of the following declarations: (CHECK A!I_«HAT i <br /> �vided for by <br /> E TraatiC1 as '.i. <br /> :id will maintain a certificate o of coerformance of the work for-ins ure for kwhich this r:=rniit s'� Labor Code, <br /> 3700 of the Labor Code,for the p iranc� <br /> permit is issued- My workers' corVe:;3a=W <br /> and will maintain workers' compensation insurance, as required by Secticr� 3700 of <br /> performance�b�a e for which this p <br /> and policy -- `f <br /> ZZ7.�c� <br /> 6s Policy Number:_LL` -3--a ny person in <br /> ae that if I <br /> fy that in the performance of the work for which this permit is issued, I steal I not er,Zpjo, Code 1 shall <br /> canner so as to become subject to the workers' compensation laws of Ca! °•coria aaxl <br /> J become subject to the workers' compensation provisions of Section 37f i l of t`a Lab <br /> An comply with those provisions. _�- <br /> 7 _Signature: i -- <br /> �jviA Fi <br /> Printed Name: LL SUBJECT <br /> 4! <br /> O JS; .•J D' �AMAGES AS <br /> +.ILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLA UL <br /> ATTORNEY d FESS„ANL <br /> App T OI NITO THE COST OF COMPENSATION NTE EST P TO ONE HUNDRED''. <br /> OR IN SECTION 3706 OF THE LABOR CODE. 4ve),hereby <br /> (C-67 licensed authe ';anal.`sr"et• <br /> n is valid for <br /> Permit Application on my behalf. I understand <br /> San Joaquin County Well this au” <br /> and Is limited to the work plan dated on the front page of this ap lieatic r,_ <br />