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$an Josquin county EnVlronMOntal Health Sarvices,Unit IV Wall Perrrilt Applicatio <br /> JOB Ap1]FtESS• 0��UtZ ,^ t`o� PERMIT 3R#' <br /> LICENSED CONTRACTORS DECLARATION LLSD) <br /> I hereby affirm that I am licensed under the provisions of chapter 9 (Commencing with Section 7800)of Division <br /> S of the Business and Professions Code and my license Is in full force and effect. <br /> L Eaense#: N W 518 Expiration Date: 5� 1 <br /> Date:. Z Contractor. �a.�: �;c D c: f '%Vi � <br /> ', Sipnaturp: <br /> Title: <br /> Printed name, ( b o ah <br /> WORKERS'COMpp.NSATION DECLARATION <br /> 1 hereby affirm under penalty of pnr9ury <br /> one of the foilOWing doo.aration0: (GHgGK ALL THAT APPLY) <br /> I have and will maintains s certl#foata of consent to self-insure for workers'cornponsatlon,as provided for by <br /> Section 3700 of the Labor Cade.for the performance of the work for which this permit is issued. <br />'I 1 have and will maintain workers'�ompensahon insurance,as regvirad by Section 3700 of the Labor Coda, <br /> for the performance of the luark for winch this per <br /> Is Issued. My workers'�mperFsatlon insurance <br /> carrier and policy numbers are; <br /> I Carrier. Policy Number: <br /> 41 certify that in the parfarmance of the work for which this permit is issued, I shell not employ any person In <br /> any manner$o as to baoantes subjact to the workers CotnpansakiGn laws of Caiifomia,and aeras that if I <br /> should become subject to the workers'tornpen$eUan provisions of Section 3700 of the Labor Code,I shall <br /> forthwith comply with those provisions. <br /> 12-Li <br /> hate: <br /> 10 _Signature: p <br /> printed Noma:COMVF <br /> o a► v <br /> WARNING.FAILURE TO SECURE EMPLOYER TO CRIMINAL pENALT)ES ARD CIVIL FINES UP TO ONSATION NE HUNDRED THOUSAND DOLLARS <br /> AES AS <br /> I TE <br /> ($RC11j10ED,FOR IN ADDITION <br /> SECTT THE COST 3705 F THE LABORODE DN,1f Ct Ett88T,ATYORNEY'S FEES,AND DAMAa <br />{ P <br /> ("y iicensed authorind repro sentath 4 b6mby <br /> authorize U�FC7 �AiC, <br /> on on my behalf. I understand this authorization is vatiel for <br /> to also this San Joaquin County Well PQrmlt�lpptisab <br /> Ona(1)year and is limited to the WOtk plan dated on the fron3 psgq of this spplioattoth. <br /> &47.2060!141E <br /> I <br /> a <br />