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Jar 07 04 C5: 04p Wayne woodward 1 -707-374-5677 p. 2 <br /> San Joaquin County Environmental Health Services,Unit IV VVeII Permit Application Supplement <br /> J JOB ADDRESS: <br /> PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATION (LCD1 <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(Commencing with Section 7000)of Division <br /> 1 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: __ -- 2/ 0 07 9 C-27 Lviratlon bete__ <br /> Date: Z- 7 –G e-1/Contractor: _ Z�/o <br /> Signature: <br /> Printed name <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby at"under penalty at perjury one of the foilawing declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certlRCate of consert to self.irsure for workers'Compensattpr,as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> 1 have and will maintain wMar3°compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work fo(which this permit is IsSlied. M workers' I <br /> tamer end policy numbers are; Y Com pensatlan Insurance <br /> Carrier. ��li�{ e Polley Number: 05/C/OO9 ZC?_ 3 <br /> _I certNy that in the performance of the work for which this perrntt Is issued. I shat)net employ any person in <br /> any manner so as to become subject to the workers'Compensation taws of California.and agree that y I <br /> should becorne subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith Camply with those provisions. <br /> Date: —Q L/ Signature: <br /> Printed Name: � �4S�it/� /�r `j — <br /> WARNING: FAILURE TO SECURE WORKERS*COMPENSATION COV <br /> AN tJtAG>e lS UNLAWFUL.AND SHALL SUBJECT <br /> EMPLOYER TO GRIMINA!PENALTIES AND CIVIL FlNEt1 UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (2100,000.),IN ADOITION TO THR COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 370/6 OF THE LABOR COOL* <br /> I, �✓f t Y eL/G /. Li I(l ,(Gsr licensed suthcrfz.d representative),heroby <br /> authadze <br /> to seen this San Joaquin Caanty well Permit Application on my behalf. 1 understand this autharizAMan h vzIld for <br /> ons{t)year and is limited to the work plan dated on the front page of this Wplk=Uon. <br /> 5-1 F4000/am <br />