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1V.&aicuVj nby U8:18 FAX tflUU2 <br /> S./ <br /> Ban Joaquin County EnVirn..mantiil Ht>;rith Service ,llnit tV Wt{t Perrnit Application$upptvmeni <br /> JOB ADDRESS: � �0 PFirfMiT SR#t <br /> LICENSED CONTRACTORS DECLARATION (.I QP) <br /> I hereby affirm th-M 1 Arn lioen"d under mo provisions of Chapter 9 (oommencirg with Seution 7000)of DivWon <br /> 3 of the Svsiness and Professions Cole and my license is In full force slid effect. <br /> License#: �I M.'1 Expiration Date; <br /> Dow <br /> contractor: <br /> Signature, Title: <br /> Printed name: <br /> MPENSATION DECLARAVON <br /> WORKERS'COMPENSATION � <br /> I hereby affirm unoor penalty of perjury one of the following daclarailons• (CH CK ALL THAT APPLY) j <br /> I have and will, maintain a p*rtificste of consent to self-Insure for workers' compensation, as provided for by <br /> /Section 3700 of cho labor CoUe,for the performance of the work for which this permit i.•+Issued, <br /> he Labor <br /> v <br /> for eve end the porforill maintain wurkers'comPensffdOn mance of the work for Which this permit Isijed roMy workquired ers' compensa tont nsu anccC o <br /> carder and policy numbers ore: <br /> Carrier: Polley Number: . .,; <br /> I certify that in the perforrrian:,e of the work for which this permit Is issued, I shalt not employ any person in <br /> any manner so as to become subject to the worktrs'compensatlon laws of Cslifornla, and agree that if) <br /> t should become subjtot to the workers'compensation provisions of S tion 3700 of the Labor Code, I shall <br /> forthwith oinply with those provisions. <br /> �L� gi»nftturer L-L-k: �u., <br /> _ Of,tte: <br /> Printed Nemt: <br /> WARNING.FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> ISH EMPLOYSR TO CRiM Hoh.L PENALTIES AND CIViL rcmesiUP TO-ONE HUNDRED THOUSAND�?OI.1-AR3 j <br /> ( ADDITION TO <br /> SECTION 3HI OF THE Comp CODE, <br /> ON,INTEREST,ATTY' <br /> ORNES FEES,AND DAMAt:E9 AS <br /> PROVN00C FOR ill <br /> i , C•137 llcv t1 surhorrted ropwsent tins, itcroby <br /> � _.._.._.._cr,, ► � � .� � `;���^ <br /> 12 <br /> autttorizs - <br /> to vign this Son Joaquin CounW well permitAfpplicstion on my behalf. 1 understand this authorization is valid for <br /> ene 1 oar and is llrnitso to the work pion dated ort the fronte�pa of thl*1pplicatfon. <br /> I aaa� w7r1, <br />