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Jan Z5 04 02: 40p W_e"oee uooduiard 1-7007--374-5677 p. 2 _ <br /> 01/2S/2004 15:10 209-2225 MODES70 ATC PAGE 03 <br /> San Joaquin County Environmental Health Swvtaes,unit IV iffa11 Parrnit Application Su"Ienrent <br /> JOB ADDRESS: PERMIT 8RE: <br /> LICENSED CONTRACTORS DECLARATION <br /> i hereby affirm that I arr licsnaed under the provisions of Chapter 9(c nuv arcing wM Section 7000)of Division <br /> 3 Of the Business and Professions Code and my license tF in full.force and sfKact. <br /> Llcenaelf: 'ZAM-7 (e-S''7 Expiration Dais: <br /> DNAs: z/a�l� Contractor: <br /> Signature: Title:Ar <br /> Printed narnr iViSi /1A�,,, fl <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm ur►der penalty of perjury one of the following dedarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to seNnsure for workers'compensation,as provided for by <br /> Section 3700 of the labor Code,for the performance of the work for whit h.this permit is issued. <br /> I haw and will maintain workers'oompenaatton hwrince,as required by Section 3700 of-the labor Code, <br /> for the performance of the work for which this permit Is Issued. My workers'Compensation insurance <br /> carrier and poky rwmbara we;o%%F;i 6 <br /> Carrier: .!54 fi' -6- i v.A Policy Number: n e-1C/Q00 Q6.1. 5�k 71 <br /> _I certify that in the performance of the work for which this permit is Issued, I shag not empty any person In <br /> any merman so ss to boom*subject to the woriars'compernation Is"of Catifomie.and agree that if t <br /> � ayaubl tom:a workers'compensation provisions of Savior, 3700 of the tabor Code,I shall <br /> provisions. <br /> Date: // Vxdr/ Signature: <br /> Prlr+ted flame:_ A IE 1.J0)6W 4 9Io.Q <br /> WAMMG-FARE TO SECURE WQRKERa'COWIINSATM COVgR^=13 UNLAWFUL.AND atwli SuttuEC7 <br /> AN ONFLOYM To COWMAL PENALTIES AND CIVIL FiNIN UP To OW Nttmomp TmOUSANO DOLLARS <br /> Irit00.tI00 IN ADDRION TO THE COST OF OOMP111IlSAT10N.INTEREST.ATTORNEY'S Films,AND OAMAMM AS <br /> PROVIDED FOR IN SECTION 37"OF THE WOR CODER <br /> (C•97 Ilaonaad euthortssd repnaentall"),h"by <br /> to sign We,San Joaquin County was Pwmft Application on my behalf, 1 understand this outhoriseti"is valid for <br /> ere(1)year and le f had to v»warfc pian dated on the front page of%bia appaaamon. <br /> a•1T /IW <br />