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San Joaquin County Enyirorimantal Health Sere as,U "t WelivermRAPpiicatloh SuPptcrnerlt i <br /> s ,NQS ADDRESS: 5-60 PERMIT $Rff: <br /> { <br /> E <br /> r <br /> L[CENSEU CONTRACTORS DECLARATION (LGt3) I <br /> I hamby affirm that 1 am licensed under tho provisions of ChWer 9(commencing with Section 7000)of Division � <br /> 3 of flys Busimss and Professions Code and rry license Is in full force and effacL <br /> l.i:anse �;. ZEx�iiration Date:—�, <br /> Date-- -11. Contractor. I/�p ' <br /> �r <br /> Signature: 7, Titlo. Pfzl�y� CN <br /> Printed narste: EIIAl <br /> WORKERS'COMPENSATION DECLARAMN <br /> t i II <br /> I hareby affirm under penalty of perjury one of the following deLyarations,_ (CHECK ALL THAT APPLY) I <br /> I have and will nieIntain a c en?icats of consent to self-Insure.for mors ers rompensavon,as prayidioo for by = <br /> Saciion 3700 of the tabor Code,for the performance of tha work for which this permit is issued. <br /> I 1 Clave end will maintain workers'compensation insurance,as required by Seclion 3700 of the Labor Code, <br /> for the performance of the work for which this permit is Issued. My wnrkers'campons,$ion insurance <br /> Corner and Policy numbers are: i <br /> c[ �- r � "} t W t <br /> Carrier*._) Policy Number. �7 8 �� <br /> I certify that in the Parforroance of the work for which this permit is issued, I $hast not employ arty parson in � <br /> ony mariner so as to aecorne sub)est to the workers'oornpensatlon laws of California,and agree that if 1 <br /> should become subject to ttxt workers'compensation provisions of Section 37017 of the labor Cade,I Sflali <br /> forthwith Comply with those provisions. <br /> bate; Signature; <br /> Printed Name; <br /> WARNING:IRAILURE 7o 51;CuRE vl ORKERV 0QMp"SA7fom COVERAQU IS UNLAVYFVL,AND SHALL StJUJVCT <br /> ACV EMPLOYER TO Ci<ifMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRM THQU SAND DOLLARS <br /> ,S100,000.),IN AODITION TO THE COST OF COMPENSAMN,INTEREST,A7TQRtlt_Y'S TEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3100 OF THE LABOR Gt3nE. I <br /> I, � A 1 <br /> �ZIrT�C ! C► Q l (G-57 licensed Atf#hOHiea rrprRSRtitstiYg),herrY <br /> to algn this San JOaQYln County Well Penrdt:AoDileation on tic/behalf. I ratrrtcrstarrd X715 as,tharizatfan iS Y2lttd tvi <br /> cne(1)year Ind Is limited to ft work plan dAtad on the front page of this app'lcattion, <br /> 3t7•sauo�Mit <br /> IZ 00 33509 <br />