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N <br /> SanJoaquin Ceurxly EmimnrrlMtal Heatfh Department Unit IV Welt Permit Application Supplement <br /> JOB ADDRESS :_ 1 SDC S 4itt1 PERMIT 3R#: <br /> SFa tc}d \ I t R 9S�lnG <br /> LICENSED CONTRACTORS DECLARATION <br /> t IWOby affirm that I am Iieensed under the provisions of Chapter 9 (commencing with Section 7000) of DNinior <br /> 3 of the Business and Professions Coda and my license is in fall force and effect. <br /> ILicense # ��� � 5 n Expiration Date: - 3 ) — Q L <br /> Date: - 1 a - 0 retractor: Letj <br /> ISignature: Title: f <br /> Printed near; <br /> WORKERS' COMPENSATION DECLARATION I <br /> I hereby 8111Rr1 under penalty of pedury one of the following declarations- (CHECK ONE) <br /> I have and will maintain a certificate of eonsenl to saiNnsurs for workers' Ogrrlponeation , as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for whleh thb permit I$ issued, <br /> t have and will maintain workers' compensation insurance, as requved by Section 3700 of the Labor Code, <br /> j for the performance of the work for which this permit is issued. My workers' compensation vleurance <br /> tamer and policy numbers are: <br /> Carder: \Q abonCL Policy Number: <br /> I I certify that in the performance of the work for which this permit Is Issued, I shall not employ sere person <br /> any manner so as to become subject to the workers' compensation laws of Callfomia, and agree dai It I In <br /> should become subject to the workers' crxnpensal on prnvl$ s Sect 3700 of the Labor Coda, I shall <br /> forthwith comply with those provisions. <br /> Data: l 0 ` 1 4zl- c3 Signature: <br /> Printed Name: <br /> WARNING: FAILUft TO SECURE WORKERS' COMPENSATION COVERAGE= IS UNLAWFUL, AND SHALL SURJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FiNPS UP TO ONE HUNDRED THOUSAND DOLLAR$ <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSA17ON, INTEREST, ATTORNEY' S FUS, ANO DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF TH6 LAROR CODE <br /> ZA .. <br /> RIZAT N FOR 0THER THAN Ca57 SIGNING PERMIT APPLICATION <br /> (signature efCme7 11owu"d suthorfsad representative), <br /> t+erobyauthorize IPd naR+e)_ I`\ NM 1 1 r . <br /> to-sien this Son Joagetn CauMy Well Peres! llcarvan on m l' I <br /> APP y banal Undeotemi t'hle nuthwizatlpn Is Ya11Q for <br /> year and Is limited to the work plan dated on the front pager of th4 application. <br /> B-29-421 MI <br />