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San Joaquin County Environmental Health t2epartment Unit IV Wall Permit Application Supplement <br /> ,SOvTkWC!Pr COkP6! 0 w6S'r y✓A1,1VU7 E"' <br /> JOB ADDRESS:A ND •a VVr'"N A1A,iV ;..._ PERMIT SR#: <br /> LICENSED CONTRACTORS DECLAMATION LCC] <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is i6 full force and effect, <br /> License#: G—6-2 '7 1 DD`7 Expiration Date:47�,djf—Z—a 0 <br /> Date= 12--H—Q-7 Contractor: 9 P i GLd NC, <br /> Signature: _r a Gam- Title: PRAM:&&LL_ _ <br /> Printed nems: W C-("Cz a- {f ock lmb� & <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations! (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code.for the performance of the work for which this permit is issued, <br /> I have and will maintain workQrs'compensaticn insurance, ae required by Section 5700 of the Labor Code, <br /> for the performance of the work for which this permit is issued_ My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: {.. l policy Number: <br /> I certify that in the performance 9f the work for which this permit is issued, 10211 not employ any person in <br /> any manner so as to become subja-ct to the workers'compensation laws of California,and agree that if I <br /> should bmmme subject to the workers'compensation provisions of Seotion 3700 of the Labor Code, I shall <br /> forthwith comply with those proviaicne, <br /> 1 1� <br /> Fxplratinn Dats: (617,008 .QiigndttlYG: C/ � <br /> Printed Name: 6QJ Cil Adr. 115- <br /> WARNING;FAILURE TO SECURE WORKERS'COMP110ATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONp HUNDRED THOUSAND DOLLARS <br /> ($igq,gpp.j,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 37at3 OF THE LABOR CODE, <br /> AUTHORIZATION FOR <br /> J�OT,H�—ER� THAN C-57 SIGNING PERMIT APPLICATION <br /> I, <br /> (57 (signature(signature of"7 licensed authorized representative), <br /> hereby authori=e(prim name) <br /> to sign this San Joaquin county well Permit Applic4on on my behalf. I understand this suthorizgtion is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this appli"tion. <br /> 8-29-02 I MI <br /> FAD 39.03.00.1 <br /> 6,/3104 <br /> 70 39vd N01iVIG3W3N OZ3 bCZ9-ICB-T99 ZE!Lt L09ZfbT/ZT <br />