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V <br /> Earl Joageytn county EnvMonmental Heats sarvie:aa.Unit IV tiYeN Permit Application Supplement <br /> i .LOB ADDRESS: PERMIT Mt. <br /> I <br /> I LICENSED CONTRACTORS DECLARATION (�Q) <br /> I hereby affirms that t am licensed under the provisions of Chapter a(wmmen mg with Section 7000)i of Division <br /> 3 of the Bue06641�narW Prd�iors Code and my license is in full force and <br /> effect <br /> 7:.TV <br /> License e. 7oAI Expwstion pate: 1 U1fX? <br /> IOats: ntradw: <br /> Signature- - - Title: ctU4,VA,, j <br /> poll MWW: <br /> { <br /> WORKERS'COMPENSATION 09CiI„ARATION <br /> I herby AMrM ender P"Iy of perjury one;of the following dacisrawins, (CHECK ALL THAT APPLY) <br /> _i have and wpl rmW ten a cartlhcste of con"M to self insure for woricers'compensation me prov ded for o,/Section 3700 of the Labor Code,for the performance of the work for which this permit is issued <br /> 1 have end wioi nearlW <br /> in workers'compenabn ie <br /> tlsuraree.e,as required by Section 3 700 of the tabor Code. <br /> for the pl Rmance of the work for which this permit;s isawo. My workers'compensa0w mswance � <br /> Carr ler and policy numbers are: <br /> "� I <br /> Carder.• 60ki8n _nG Posey Number: <br /> I that in the of <br /> _ p1t10►manCt! the work for which this permit.s issued,I sF.aM not employ any person .n ' <br /> any manner so as to become subject to the workers'conwweaticn lava of Cauomia, and agree that It I <br /> SWUM DOW"aelbject to the workers'comp~ion provisions of Section 3700 of the labor Code. 1 sRal: 1 <br /> forthwith comply with those provelons <br /> Dace: sire tare: l <br /> PdinW Nance: <br /> MIARIMING: FAILURE TO BLCURE WOM EOW COIIPM41SATION COVERAG818 UNLAWFUL,AND SMALL 8USJECT ' <br /> AN VAPLOYOt TO CRMMNAL PENALTIES AND CIVIL.FINES UP To ONE HUNDRED THOUSAND DOLLARS <br /> ($10C.000.L All ADDITION TO THB C,OSTOE COMPPISATION,WTEREST,AYTORAMY'S BEES,AND DAMAGES AS <br /> P100"7EO FOR 0 UCT1001 370 OF THS LAS COM <br /> ,Z'. i <br /> bcal liaeresed authorised rpreeentativwR herby <br /> autl�ori=e �'l�T. A s� � <br /> to MY^thio Sear Josgeein County Watt Permit Applietatloe on my bd%W. I undo nlAind Oft authorization is valid fo► <br /> ode N►Vest and is limftd m the work pian dated an the Moret pale of*W a icatior ---- <br />