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01/26/2006 TIM 15:30 FAX 0 002 <br /> -71 <br /> ---- ro r Ir ;+[iursu k merit <br /> San Joaqui oun virinmverfal Ittl Department iit IV Weil Cerin t/,pp 'r:-. PI "Z <br /> JOB ADDR S: . .� H� � PERMIT SR#. DQffl7 <br /> LICENSED CONTRACTORS DECLARATION (Lc� <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencirig with Section 7000) of Uivislon <br /> 3 of the Business and Profes�Ls-ions Code and my license is in full force and. ffed. <br /> License 9: D {' n k7gte: -A - <br /> Date . Contra <br /> signature• - <br /> Printed name: <br /> WORMRS' COMIPENSATI DECLARATION <br /> I lr_reby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> r have and will maintain a certiricate of oonsenf lu self-insure for workers'compensation, as provided for <br /> by Section 37,00 of{he Labor Code, for ilia performance of the work for whirh this permit is issued. <br /> I Clave and will maintain workers' compensation insurance, os required by Section 3700 of Uic Labor Colt?, <br /> for the performance Of#10,work for which this permil.is issued. My workers'compeng�ation iin"s}uraannc(e� <br /> carrier an policy num are- V I DEiL I .1._ <br /> CwTier. Policy Number., <br /> certify that in the performance of the work for which this perMit is[%sued, I shall not employ any person in <br /> any mannerso asto became subjer i to the workers compensation laws of California,and agree that if 1 <br /> should become ubject to the workers' compensa 'an provisions of Section 3700 of the Labor Cade, I shall <br /> fortgh ith com wibt those provisions. <br /> Date:_`��1c`� $r9 nature: <br /> Printed Name: <br /> WARNING:FAILURE TO SLOURE WORKERS'COMPENSATION COVERAGE Is UNLAWFUL,AND HUD.JECT <br /> AN EMPLOYER TO CK�IM]NAL PENAL-1-12Z AND CIVIL FlNr's UP TO ONE HUNDRED THOUSAND DOLLARS <br /> M00,D00Q,IN bAD SECTTO ION ON HE COST OFTI EFLECODF <br /> COORIoN,INTEREST,ATTORNEY'S FEES,AND vAMAGIES AS <br /> pROVIDED.F <br /> TtiQf2IZATtON FI IR Q THAN C-57 SIGNING PERMIT APPLICATION <br /> atnry ,censeda 4horiZedreP2sentafiveir <br /> hereby outhvdi (print nam)^, �V,` <br /> ry ;yn Fhre eT„-],•:•7wn rtnnnfy all Permit APRII[.at'inn an my behalf. I understand f„ix aeltbcr4.:rtlen is va![l for <br /> one(i)year A3 is;limited io thn work plan dro'tad on the frorrr page of tbr3 appncatroi 1. <br />