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05/21/2005 FRI 15:48 FAX 2002 <br /> San ioaqufn County Environmental fteafth services,tinit.lV WeII PermitAppiicat[on Supplement <br /> PERMIT <br /> JOB ADDRESS: 1 3f <br /> 'd� I <br /> LICENSED CONTRACTORS DECLARATION (1-100 <br /> I hereby affirm that I am licensed under the provisionsinse s In full force and effect. with Section 7000)of Division <br /> 3 of the Business and Professions Code and my <br /> ti�l0 D,y Expiration Date: ) � <br /> License#: /CA <br /> ontractor. Y <br /> Date:, Inst-- — p�k}.(v/LCJU <br /> Title: <br /> Signature: 1 <br /> Printed name: Joel <br /> WORKERS' COMPENSATION IJECLAhATION <br /> I hereby affirm under penalty of perjury one of the following declarations (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation,as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit s issuedtion . <br /> ction 3700 <br /> e Labor <br /> for the performance I have and wiijrintai wowork' GOMPen this permit r is Issued requiredce, as Myworkers'ecompensati n sura ce ode <br /> he <br /> carrier and policy numbers are: <br /> –bl& �A t– _ Policy Number. ll n3t��. <br /> Carrier: <br /> I certify that in the performance of the work,for which this permit is issued, 1 shall not employ any person in <br /> s of California, and agree that it I <br /> any manner so as to become Subject to tshall <br /> rovisions of S ,ion 3700 of the Labor Code, <br /> hworkers compensation law <br /> should become subject to the workers' compensation P <br /> fo thwith ompty with those provisions. <br /> Date: Signature: <br /> pi . \f; r IhPvul <br /> Printed Name: -- <br /> AN NTNG: FFAILURE CRIMI,ECURF WORKERS'NAL PENALTIES AND OCIVIL FINES UP TO ONE HUNDRED THOUS AND DOLLARS <br /> ESA.Ti.ON COVERAGE IS UNLAWFUL,AND SHALL WARUBJECT <br /> ($100,000.),!N ADDITION TO THE COST OF COMPENSATION,INTERE5T,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ( -57 lieensed authorized mpresOntativ6), hereby <br /> authorize <br /> Weil Permit APPlicatlon on mY behalf. 1 understand this authorization is valid for <br /> to sign this San Joaquin County — <br /> il)Y <br /> ear ands limited to the work plan datedOr..,t.... front page of this application. <br /> one <br />