Laserfiche WebLink
FILE COPY <br /> San Joaquin county EnvLranmcntaf Health Sesrvlcos,Unit lVW4hII PerMlt APPl1Cattorr Sunplsn►W i <br /> JOO S. PERMIT <br /> r <br /> I <br /> LICENSED CONTRACTORS DECLARATION (LCD) � <br /> I hereby affirm that 1 am licensed under tho provisions of Ch_pter 8(commencing with SeCtlon 7000)of Divi9Fon <br /> 3 of ilia Buslness and Profasslons Code and my itcen=is in full farce and effect.' <br /> Ur-anse 4: f�. Z ! -1 Eviration rate-_ (,a <br /> ` <br /> Oafs_ J:� ContrdCtor, l File, rQ.��,..� <br /> Signature: f�Titlle;:-y� 1 G V <br /> - L...�!_l�� i <br /> Printed nm <br /> ae: _., <br /> WORKERS'COMPENSATION DECLARATION I <br /> i <br /> I hereby affirm under penalty of perjury one of he following det larations: (CHECK ALL THAT APPLE) <br /> I have anti will maintain a cc.ftlficat8 at consent to selFinrura for workers'rarripens�atron,as pravltled{41 by <br /> ! Saction 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> ' I bare end will maintain workers'compensation insurance,as required bySeclion 3700 of the Labor Code. <br /> for the performance of the work for which this parmit is Issued. My workers'cornpensaVon insurance <br /> Merrier and palls numbers are: ' <br /> c� s <br /> 1 <br /> Carrier. lV Policy Number; <br /> t Certify that in the perfarmence of the work for which tills permit is Sssued, I shall not employ any parson in E <br /> ony manner So as to become su0ject to the workers'Compen*atlon laws of California.and agree that if 1 <br /> should become suhjed to lie walkers'cornpensaUon provisions or Section 3700 of the Labor Coda,f shall <br /> forthwith comply with those provisions. <br /> bate: Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'CCIMPENSATMN COVERAGE IS UNLAWFAM,AND SHALT.SliEUVCT <br /> AN EMPLOYER ER TQ CRIMINAL PENALTIES AND CIVIL FiMEs UP TO ONE HUND"D THQUSAND DOLLARS f <br /> ;tbtt,DQtl.),IN ADDITION TO THE COST OF Ca_7MPEiNSATM,INTEREST,ATfORNE r-5 FEES,AND DAMAC�E5 AS <br /> PROVIDED FOR III SECTION 376a OF THE LABOR CODE. 4 <br /> !. � Ci 6���� ! C:. t?d (C.ST ucensrd autl5artiaa rept�scnta[iVR},hat��Y <br /> authors �"L IV-A- Ar micd L11 n <br /> to sign this San Joaeuin Caunty Wats PermltAoDlicgtlon on lay behalf, l uhdcrstand thin:kulhofix3t)an ie vagd;ai <br /> one t1j year and Is l rnitsd to ow work pian datod an tho front page of this app'icatton. <br /> 6.17.2t1t10 l MI <br />