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07/10/02 WED 13:10 FAX 650 6919837 SECOR <br /> �idooa <br /> Sail.toaqu1n county Envirosttbrltal Hiaallt,-h$9rallc/ea,Un IV <br /> iIVa11 hermitAppS'scation Su P1st�+cr+t <br /> JOB ADDRESS; 1.�� G� r�/�� lfc�- . PERMIT SR#; <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby offirrn that I om licensed under the provlsions of Ctraptcr 9 (Corrirrmricing With Section 7000)of Divlaren <br /> 3 of the business and Prafassions Code and my license is in full farce and effect. <br /> License# Expiration Date, <br /> Date: ,_l . v <br /> S' nature: I.LTitle• <br /> Printed name: � — <br /> WORKERS' COMPENSATION DECLAFZATION <br /> I hereby affirm under penally of perjury one of the following deoiaroticns: ICNECK ALL THoT APPLY) <br /> I have and Sect on 3700ofthie Labor Code fan the parformance of the work for which this pesrmit I%Issued.provided for key <br /> I have and wlii maintain workers`gornpensetion insltrance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. tiny work8m' corripmnsstlah insurallcp <br /> caviar and pollcy numbers are: <br /> Carrier: Ll Policy Number: <br /> I certi[y that in the performance of the work for which this permit is issued. I shalt not employ any parson'n <br /> any rnanner so as to hecorna subject to the workers'compensation lawe of CaWornia, arld a4l'sa that if J <br /> should became 6ub)ect to the workers' compensation provisions of Sestian 3300 of the Labor coda, I shali <br /> forthWith comply with these provisions. fr , <br /> Date, Slgnat re• <br /> printed Name: <br /> WARNING'1-AlLURE TO SECURE WORKERS' COMPENSAT10N COVERAGE 15 UNL.oWFtJI,AND SMALL SUOJECZ <br /> AN EMPLOYER TO CRIMtr AL pMMALT1ES AND CIVIL FINES UP TO ONE HUNDRFD THOUSAND DOLLARS <br /> {S1 DO,t1G0.},IN ADDITION TO TNF. COST OF GOMPENGATION.INTEREST,ATTORNEY'S FEIeS,AND DAMAG _S AS <br /> PROVIDED FOR IN SECTION 3706 OF THF-t-ABOR CODE, <br /> 1, C-57licCrteed.aUthofized repravantAtiyc}, Izerob <br /> authorlte r <br /> to sign this San aoaqutn Courtly Well Perm Hearten o mY behalf. i undem%and m1m avthortzntion Is Bali yr <br /> one1 +tsar and isu lirnttgd to thew �n dates[on the Front page of tbI2 applic ition. <br />