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p lementt <br /> San JaAquln Gauntly 6nvtronmantal Healtlr DepaHmsnt UnR N We11 Parmlt ApPYoaHon supplement <br /> JOB ADpRI s:3' PERMrr SR# ,. <br /> LICENSED CONTRACTORS DECLARATION ( , <br /> hereby of ern that I am licensed under aw previSlol't6 of Chapter 9(eomrnerc#V with Section 7000)of Division <br /> 3 of the BusvrPss SnO Prefesaions Cade and my license is In full force and effect. <br /> ~ <-- <br /> .�.--- <br /> as zo I Data: �O—CI <br /> 8=61 <br /> Signature I / Title; r' <br /> Printed Hama EC ✓16 rc L 1 ��. <br /> wORKER5' COMPENSATION DECLARATION <br /> I hereby efrmlr under penalty of perjury one of the following daderstions: (CHECK ONE) <br /> l __i have and vin maintain a certificate of torpent to self-insure for works%'wnpensatlon..as provided for <br /> by Section 3700 of the Labor Code,far the performance of the work for which this permit h iswed. <br /> I hive and will maintain workers'compensation inwranee,as required by Section 3700 or the Labor Code, <br /> for the performance of the work for which this permit Is Issued. My wOAuxs'Wmpens*W 1 insurance <br /> carrier and policy numbers <br /> are: C�p�" / <br /> CarAer� f 1�2 —Polity Number ZJ O lY lJ' <br /> I mrtify that In the performance of the wok for which this permit is Issued, 1%fedi not employ any person to <br /> any manner so as to becnme subiect to the workers'compenWon laws of Cwthmia,2m;1 agree that if I <br /> should become subject to the workers'Compensation provisions of Seddon 3700 of the L.hor Code,I shall <br /> forthw"comply with those provisions, <br /> Data: Siynatune:_ <br /> Printed Napes: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND INIALL SUBJECT <br /> AN fitIPLOVER TO CRIMINAL PENALTIES AND CML FINS UP TO ONE I-MI)RED THOUSAM CUOLLARS <br /> (3109,000.).IN ADUMN TO THE COST OF COMNSAMON,INTEREST,ATTORNEY'S FEEB,AH a DAMAGES AS <br /> PROVIDeD FOR IN SECTION 3786 OF THE LABOR CODE <br /> AUTH <br /> O <br /> R <br /> IZ <br /> ATI <br /> O <br /> N <br /> FORp�THAN C-57 SIGNING PERMIT APPLICATION <br /> .TT. <br /> (sili/nvium�arV authaAadmprosenativel, . <br /> hoeabyauthefte(Printname) ,AOA QI�ft7{ O r Acayt}LKeOr 66 V,,-onmedaJ_ <br /> to coign chis Ban rosqurn t aw>!y Woll Pa►nR Apppcatian on my baluyt. 1 undorstnnd thls nutlw imil6n Is valid for <br /> ons(1)year and ie lindted to dw work plan dated on the front pays of this gw1k:aUon. <br />