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JOB ADDRESS 1k HaMrre-y- PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code)and my license is in full force Ia1ndeffect. <br /> '-1 <br /> License#: �p�G�y / Expiration Date: -'Z)i�'-00 <br /> Date: _ o '�/ Co ctor: �1 �� ('A\In . n"Inc- . <br /> Signature: Title: l�//lQLrQ�UL¢�l� <br /> Printed name: + A ��,i jfr( e <br /> JJ WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> Z1 have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier(and policy numbers are:l7 <br /> Carrier: aden ea0 <br /> 4Policy Number: 0: <br /> I certify that in the performance of the work for which this 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 become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTIOM 3706 OF THE LABOR CODE. <br /> (C-57 license holder), hereby <br /> authorize rI of f•C l C 85�X r i Me (consulting),to sign this San <br /> Joaquin County Weil Permit Application on my behalf. I understand this authorization is valid for one(1)year <br /> and Is limited to the work plan dated on the front page of this application. <br /> l <br />