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9-10-1997 0:00AM FROM P. 2 <br /> rl.ii�c1[tti3a i��:1f l£Z -�7'�� MC3L '�Til C PAGE via <br /> San Joaquin Campty srnvirnnmental health.Services,Unit IV Will Pantmtt Application Suppietnsnt i <br /> i <br /> JCJS ADDRESS: PkRMIT SRX: <br /> LICENSED CONTRACTORS DECLARATIONLf,C,,.D <br /> I <br /> 1 herovy offirmn !hot I am licensed under tfte provisions of Chapter g(romraenClnO with Sectfon 7000)of Division . <br /> 1 3 of the i3Usinea3 and ProfessionS Co"and rrty itetertsn ls.in IWI 1004 8..10*V016-t. <br /> i.con>fe to�. A ixp►ration oats: . <br /> signature" �' � -- nuo:.._C11d.!�( _ <br /> Printed nmme: �� Y I SGi�- <br /> , <br /> f WORKERS' COMPENSATION DECLARATION <br /> , <br /> t , <br /> 4 i hereby affirm under penalty of perjury one of the wowing declarations: (GMtiCK.AL.L THAT APPLY) <br /> r <br /> l have and will maintain a certiticate of consent to saif,-insure for workers,c;nrnpertsatian,AS provided for by <br /> i Section 3700 of the Labor Code,for me parferMaMCe of the work for whieh this permit is isxued. <br /> i have and will Taintain Workers'compensation insu-ante,its.meCufred by Section 3700 of"Labor Code, <br /> for the perfo•rrnance of the work for which this permit is issued. My workers' compensation insuranCe <br /> canter and PCA&'y r.tw:tbem a(-e: <br /> Carder: 1. ----......,�.Polley.lYutntrer <br /> l certify that in the 0erhtrrmance of tM I work for which this peE."n'tit is Issued; i shall not employ any person in <br /> any rnenner sfl as to become subject to the workers'compensation laws of Califomia,and agree that It i <br /> should become Subject t0 Me workers'compensation provlalans of Section 3700 of the Labor Code. I shell <br /> t forthwith;((Comply with those provisions.. <br /> Date:- I,,• o.....,�...Slgnature' .►�` r . <br /> Printed Name: �'� (� �•�c� <br /> ! WAIRN)NG: FAJLUF E TO SECURE WORKERS'C0MPEN3A=N.CP.VVtA0JE I3 UNLAWKL.AND.3"At.t.SUBJECT <br /> { <br /> AN BM/�P/�1.0Yr;R TC C-RIPM14AL PENALTIR3 AND CIVIL S'.UC_'TO ONF.ffUNDIM THC�USAW DOLLARS <br /> (i1 OO,¢yQ.}.iN AOGi n0N T0 <br /> 't'W COST OF.COMPENZAr.ON,IWMRTi T ATrORNEY'S FEES,AND DAMAGES AS' tt <br /> PROM10 FOR 1N 3ECIMON 3,104 OF mE LABOR C.01; . <br /> j r <br /> (C•57 Ocansad authorized homby <br /> P ructt►oriae �7'• <br /> f <br /> to sign 090 Sar, J*"uin Gowity V%II f wrnttt Appircation on nay behalf. i undarstand this 6ut7todmign is valid fbr <br /> one(t)yrsr and it limited to the wor4-plan dated on the pant page W this appuaatton. <br /> �1•t7-ZGQQ.ttti. <br />