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AGE STOCKTON c P
<br /> 05!19/2000 09:24 2094671118
<br /> .a4aE Voceri
<br /> To
<br /> 05/1712@00 13:45 2994671118
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<br /> • 'JOBAppRESS ' � -, s s��, - ��,: a,.��:�,:;, .': -
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<br /> LICENSED CONTRACToRs DECLARATION (L-Q2)
<br /> ,
<br /> I hereby 8MM that)am lieensted under rile pfov?sinns Uf Chaptor 5 tcomrr+enclnq wilt}Section 7G�t ��f Uivis,t r:
<br /> 3 of the Business and PrafwsSions Cade)and My tieen5e is in full fo1�t8 and Keit.
<br /> } !:x ir0tton Aate:
<br /> license�►: ` p i
<br /> 1 GGhtC8C1W: S"i 14
<br /> '"~
<br /> Date:
<br /> Signature: "f�tle'
<br /> ;Printed rather
<br /> WORKERS' COMPENSATION D Ci-ARAT(ON j
<br /> 2"reby ellirm under penefty of perjury one of the f0owing deciarali6m, (CHECK ALL THAT APPLY)
<br /> I have and'will maintain a certifieele Of consent to seif-insurefgr workers'comp;mation, as prc. Iqr Gy
<br /> Swim 3700 of the Labor Code, fol,1he'pEh0rmanee of the work for which this permil is issv-d
<br /> 1 have and will mainfein workers'compecr,sation insuranue, as ltplred by'Section 370D of the :a
<br /> for the parfDrmalla Df the work for which chis permit is Issued, qty workeri'Compensation it 11VVIC- i
<br /> oerrier.and eolicy nu hers are;
<br /> Carrier: 1TPUlicy }durrtb&r: Ws t ....,. ,...•........ '
<br /> I certify that in the wformance of the work for/which tots perrnn is issued, I 1 lholi not emp:oy bn
<br /> Fny manner so as to become subject to the warkerS'CCmpf-ns�.,ior laws Df Celifornl$, and as tto t''?t if I
<br /> 8heuld become subject to the w6fkef9' COmpAr tatinr, prey s,c,,:c.cf Section 3700 of the Lab?r C'- Al
<br /> forthwith coMpth ly wilidle provisions,
<br /> Date:�S—� /pl- 00 Signature: _..,.,.. .
<br /> Printed Name' _ QJ_..•, .. �__
<br /> WARNING:FAILURE TO SECURE WORKERS'CQh7PENSA710N COVERAGE )S UNLAWFUL,AND SI'1,t. `_•V51JP;c' i
<br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO CNE HUNDRED THOUSANC) DOLL NS
<br /> (S100,00O.),IN ADDITION TO'THfi Cp�,Y QF Gpt►P �+SATIi�N, INTEn£87,AT'Oi�1aEY'S PEES.AND Cl.I,'/•t'aE.� %`i
<br /> PPOVf0EED FOR IN 6ECT)O�JN 97/05 OF THE/rLA60R CODE..
<br /> `� I, !G—L~��/9i�� /�1. �../:JIA..'7G.�'�e..:,...,.��./1.,,�._�.. __......,_._ (C57licens�;•'1c� 'I:fl, s••, r:,•,•
<br /> authvrixe 7;mk*714 y4..,. CyV U)o r - of ►✓ r�+ ' i�._.` F Q.... y • ,(c�nsuPtrn��,s'a . , ;P:+a 5trt
<br /> Joaquin County Well Pa,"It Appllrmtign on my by half, I ur♦derstal)d ft+is evlhorixstioM1 is vaild for rr-,�(11 yss►
<br /> 4r,d is limited to the wort plan dated on the front pg Se of thiF FjpplicwLien-
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