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01/26/2006 THU 15:30 FAX 0 002 <br /> Ir gtiur. S!1 k�merR <br /> San Joaquin Gounn4v-2E� <br /> crltaIth Depart'Y`ezf�rlit iV Wefl Perm t/.pP = L�����/ PERMIT SR#: �� !— <br /> JQB ADDRESS: . <br /> LICENSED CONTRACTORS DECLARATION (LCIS <br /> I heroby affirm that i am Licensed under the provisions of Chapter 9 (commencirig with Section 7000)of Division <br /> 3 of the Business and Professions Code and my License is in full force andffect+ <br /> . I �( <br /> D`7' Exp-t�atIon nate: LA <br /> VlX__ <br /> Dates. + Contra or', <br /> signature: '-. _ <br /> Printed name:`. .—. <br /> WORMRS' COMPENSATI DECLARATION <br /> l Ir perjury ono of the following declarations: (CHECK ONE) <br /> eby afiilm under penalty of <br /> _t have and will maintain a certiricate of consent to self-insure for workers' compensation, as provided for <br /> or Code, for the perfornlance of the work for which this permit is issued. <br /> by Section 3700 of{he lab <br /> %tiun 3700 of <br /> �Ihave and owil�ncetforwhchthisperm6 snisauedrMYrwodereEcornpensationtInsurance �P <br /> for the pert of the Work <br /> carrier an2Z�— <br /> -i Policy Number:I.' <br /> I certify that in the performance of the work for which this perrnit is issued. I shall not employ any person in <br /> any manner so as to become subject to the wwkeis' c0rrrpellsation laws of California,and agree that I <br /> should become ubjecA to the workers' eompensa 'on provis"ions of Section 3700 of the labor Code, I shall <br /> forth ith Conlpl with those provisions. <br /> Date:_ Signature: ^ <br /> Printeld Name: <br /> 'WARNING:FAILURE ST. UR <br /> C E WORKERS'cOMPENSATION COVERAGE IS UNLAWFUL, <br /> DOLLARS <br /> I <br /> AN EMPLOYER To CRfM1NAL PENALTIES AND CIVIL FlNps UP TO ONE HUNDRED TNOiI AN <br /> P 100,00eD:bAD SECTION 37 6 OF?t EF COMP NSATION.INTEREST,ATtORNEy'S FEES,ANn UAA9AGES AS <br /> T1iQRFZATION-,FOR PTI THAN C-57 SIGNING PERMIT APPLICATION <br /> ., ,L ig�ataro ��',Jcensnd arthorize_d refiresentaGve), <br /> Ilercby autftu,jT-((hint nam9)— <br /> W iga they Eon.lonquin Mnnly all Permit Application on my behalf, l un8nr54and tmiik auth�rla',Uen is ral[d mor <br /> one(1)year and G:tirnited o thn work plan dated an the frvon page of 4h;q apt,Erc�tUolt. <br /> _I <br />