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0002 <br /> San Jno«uin County Hnvirottrnenta! Health nepa trent <br /> ii—riR IY Well P-rrmit Atrpiication Suhplemert <br /> Jab ADDRESS:_/'?3c>o W. Ura A+ Lint t2d PERMIT SR#:^-- <br /> LICENSED CONTRACTOR$ DECLARATION (AC-DJ' <br /> ' I hereby affirm(hat I am licensed under the provisions of Ch ipter 9 (commencing with Section 7000) of Divi:;ion <br /> 3 of the Business <br /> aandd(Prrofession$Code and Iny lir..an" is in full force /anld ffect. `'� <br /> ' License 0R t �/ D� _�t'l exp}' b�n Date: '�1 V� <br /> Date: .g-Zfo. GS Contra <br /> signati0g 11t1�7 <br /> Printed name — <br /> ' WORKp 2S' COMPENSATI DECLARATION <br /> I hereby affirm -under penatty of perjury une of the following declaratlons: (CHECY, ONE) <br /> ' I have and will maintain a c:erlirwato of consent to self-insure,for workers'compensation,as proyided for <br /> by Section 3700 of the Laboi Code, furthe performance of the work forwhich thm pamiit is issued. <br /> ' I have and will maintain workers'compensotion insurance, Rs required by Seotion :3700 of the Labor Codc, <br /> for the performance of the work for which this permit Is is.ued. My workers'corripansation insurance, <br /> carrier an policy numb s are- } <br /> ' Carrier. ( Policy Number. <br /> 01 - W <br /> I certify th st in the performance of the work for which this permit is Issued, I shall not employ any person In <br /> any manlier so as to become subJcct to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensa ion provision of S'oLtian 3700 of the Labor Code, I shall <br /> forthwith Comply With those provisions. <br /> Patc:_O Z(o 'OS _Signature: <br /> .— <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SU21JE-c! <br /> ' AN EMPLOYER To CRIMINAL PENAL11P5 AND CIVIL FINeS UP TO ONE HUNDRED THOU,ANP DOLLARS <br /> (5100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNE,Y'S FCES, AN6 DAIOAGE.S A:; <br /> PROVIDED FOR 1N SCCTION 3700 OF THE LABOR CODE. <br /> ' /�(Jy1Lf/TH/OfZ17JtTION FmR THAN C-57 SIGNING PERMIT APPLICATION <br /> - I _ "Y.r)�I/'L✓� J_ _ ! (signature WC 57 licensed authorized representative), <br /> horcby auttlonzo (print namg)_„_`Cr-ed 3' `'�t NS --. — —to ugri Fh Ssuo.h,acy,uui Coilni:V dVell Pecnvt 'ippla z4k.n on nil, 6,uiii, I union,far ci( : �+lthnrlcoticr rc valid sni � <br /> rine I I}yc.{r ai,d 1,ilnii'ted to Frio vrra n C '1 dixto;l on Ll l.front ioi ',e o'r thio appnccrtlo:• <br /> 1�I <br />