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' • �doa: <br /> 0 <br /> [JOSS <br /> _ - - ' - - ._ — iJna«tile CountFE-nv!Tnwllenfai Health Department Beit IV Well Hermit AI'rf%ficatioI SuiIpIEr7�enf ADPRESs: I/OSS 1�.. 7rct/iy�i?e PERfiI it sCc7f;___ — <br /> LICENSED CONTRACTORS DECLARATiON (LCT <br /> I hereby affirm thet I am lioensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the BusineSZ and <br /> dProfessions Code and my license is in full force arid iffea /� <br /> ' License#Qy t O� _a�Expiration Delta: �t IO( //;I <br /> Date: $'Zb. bS Contra tor. <br /> ' Signatr'ire• ��I - <br /> Printed name: •� " —_ <br /> ' WORKERS' COMPI:N5ATI E ECLARATION <br /> I hereby affirm under penalty of pe.qury ono of the following declarations: (CHECK.ONE) <br /> I have and will maintain a certificate of consent to self-insure,for workers'compensation, as proyided for <br /> by section 3700 of the Labor Code, for the performance of The work for which thie permit is issued. <br /> I have and will maintain workers'compensation insurance., ns required by Seotion 3700 of time. Labor Code, <br /> for the performance.of the work for which this permit Is i;:tied. My workers'compensation insurance, <br /> carrier and policy numb s are: <br /> Carrier: GG J _, Policy N(imber.. 1'✓ 1 OI U�J <br /> )certify that in tho performance of the work for which this pemilt is Issued, I shall not employ any person In <br /> 2ny mannervo as to become eub)oot to the worker;' compensation laws of California, and agree that if I <br /> should becore rubWt to the workers'compensa ion provisions of Secdien 3700 of the tzbor Code, I shali <br /> forthwitficornplywitl4 those provision=.. <br /> Date: _ _Signature: %64 ✓�. -- <br /> ' - - <br /> Printed Nanic; <br /> WARNING: FAILURE TO GrCURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJEC i <br /> AN EMPLOYER TO CRIMINAL PENAL-11PS AND CIVIL FINDS Ur TO ONr HUNDRED THOU,S�AND DDLLARS <br /> (5100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTOHNEY'S FOES, ANO DAMAGES As <br /> PROVIDED FOR 1N SECTION 5706 OF THE LABOR CODE. <br /> ' /7HOR7IrZATION FOR QLtLgR THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofc. <br /> ec57 licenseq aufhoriznd represenfaflve), <br /> hereby au$terizo(prinUlamai_..Lled W__47�uS <br /> r' rn<ipr tht, Sew .bo3gi,111 Comll.y YY011 Perntli hppi;r.- inn on rip kshil`. 0 un iarsland f.'rie Irl ilm urlC.)4lon i vni10 fni <br /> I ..�:, q_r Ivl w the 4uu;1's p3sln,�1�,Ca;t Gr, tiro tunf I .it�e n'loris applie,^,tilos. <br /> i <br /> 1� <br />