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r <br /> IL <br /> San Joaquin County Environmental Health Services,Unit N Wail Permit Appiicattoh Supplement <br /> JOB AIDDRESS: . Ss,.o -30-, C'r Ski Ca-n tv PEitMIT SR#: <br /> crop <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affM that I em licensed under the provisions of Chapter$(cornmeneing with Section 7000)of Division <br /> 3 of the Business and Professions code and my license is in full force and effect. <br /> uoense#' 2 `i 3 _ Expiration Date:. S'3! o <br /> Date: .7- 10q Contractor: C c; i j <br /> Signature: Title: el 4- <br /> Printed name: RI Donc�hv <br /> C WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations; (CHF-CK ALL THAT APPLY) <br /> I have and.will maintain a cenitloate of consent to self-Insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for whlsh this permit is Issued. <br /> .._i have and will maintain workers'compensation insurance,as required by section 3700 of the labor Code, <br /> for the performance of the work for which this permit is issued_ My workers'corn Pam siation Insurance <br /> carrier and policy numbers are: <br /> Carrier. Policy Number: <br /> I Certify that in the performance of the work for which this permit is issued.I shsil not employ any person In <br /> any manner so as to becoino subject to the workers'compensation laws of C.atifomia.and agree that if I <br /> should becorne 3ub)ect to the workers'compensatlon provisions of Section 3700 of the Labor Code,1 shall <br /> forthwith comply with those pravlsions. <br /> Data; iZ D Signature: ite 01-4 <br /> Printed Name: Al Dovla6v-e <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVFRAGE 19 UNLAWFUL,AND SHALL SUBJECT 1II <br /> EMPLOYERTO CRIMINAL PSNAL r O comloENSATIDN INTI±EST,ATTOSAND CIVIL FINES UP TO ONE RNEY'S,8 FE�AND DAMAGES AS 1 <br /> D DOLLARS <br /> ($100A00.),1H ADDITION TO'iF1E COS F <br /> PROVIDED FOR 1N SECTION 3TQ6 OF THE LABOR CODE- <br /> -isT licensed outhorbsed representative},thereby <br /> authorize <br /> to sign this son Joaquin County Wall Permit Application an my behalf. I understand this authorization 1a vatid Far <br /> one(4)year and is Ilmltad to the work plan dated on the front page of this apPilcatlon. <br /> 6 47.20001 MI <br /> r <br />