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01/26/2006 THU 15:30 FAR 0 002 <br /> O <br /> sir ,Lien U fnenf <br /> an Joariuin CO 11 virinm�ot lth Departlr'ezt LFnit IV Weil f enn t DO p--� _ <br /> _I <br /> JOB ADDRESS:=., <br /> PERMIT SR#: <br /> rG• � , i <br /> LICENSED ONTRACTORS DECLARATION (LCT <br /> I hereby affirm that 1 am tioensed under the provisions of chapter 9 (commencing with Section 7000) of IJivi$IOn <br /> 3 of the Business and ProYes(siions Code and my license is in full force a'nld. ffect. <br /> License ' <br /> 0� Expt�ation Pgte; �1 <br /> POO:. Contra <br /> T1tle. <br /> Signature: - . <br /> Printed name: — <br /> WORKME:R ' COMIPENSATI 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 !u self-insure for workers'compensation,as provided for <br /> by Section 37.00 ofihe Labor Code, fur the performance of the work for which this permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Ser:tion 6700 of Nrc Labor Code, <br /> for the performance of the work for which this permit is is,ued. My workers' compenfs}ation insurance <br /> .�carrier a�Q� <br /> V'_ policy Number: - <br /> certify that in the perfomtancr+of the work for whichthis permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of California,and agree that if I <br /> should bedome subject to the workers' compensa'on provisions of Section 3700 of the Labor Code, I shall <br /> forth ith icons whit those provisions. <br /> Date: `� Sr9nafure; <br /> - <br /> Printod Name: � <br /> WARNING:FAILURE TO SCIQURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,A a SHALL SUDJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINNS UP TO ONE HUNDRED THO(13AND DOLLARS <br /> p0C10j.IN ADDITION TO THE SECTION 3JUG OFTf ECOST <br /> Ft4oA <br /> COMPENSATION. INTEREST,ATTORNEY'S FEES,ANn DAMAGES AS <br /> ROVUHD:b <br /> TliQW. Z IONFOR O,T�FRTHAN C-57 SIGNING PERMIT APPLICATION <br /> Iii to censbd a thort¢ed representative), <br /> hereby euthuilr- (prl nt namn)_ <br /> (y�i,n rh%p ori Permit Application <br /> On my beha R, t understand V.-6s auth�riz eA(On is rr.![d Tor <br /> We(1)year and Ir limited is the wcrK plan&aQd on the frurrz page of 4b%e appncrtiort. <br />