Laserfiche WebLink
Gift of ST.oGK , ttiN S10 � \NALK <br /> JOB ADDRESS : 130 N , TAUNTER ST . $ 'I0CKTON PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <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 and effect. <br /> License # 6 � 3 8 k 5 Expiration Date y ' u: a Z <br /> Date I I ZI - 6 d Contractor l S C i� L N 1 It 0 N M 6 N T K <br /> Signature7:i;; � <br /> WORKERS ' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decalarations: <br /> 111 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 /> 1 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 carrier <br /> and policy number are: <br /> Q l 1 Policy Number l 5P 2as - ao <br /> Carrier �"T� i�P <br /> rmance of the work for which this permit is issued, I shall not employ any pe <br /> ❑ I certify that in the perforson in any manner <br /> so as to become subject to the workers' compensation laws of California , and agree that if I shouldecome <br /> (hoseprovisions. <br /> the workers' compensation provisions of Section 3700 of^the Labor Code, I shall forthwith comply <br /> Date / IZ/fid Applicant UaVE� <br /> WARNING : O CRIMINAL PENALTIES AND COMPENSATION <br /> FINEST UP TO OERAGE SUBJECT <br /> NE HUNDRED THOUSAND DOLLARS <br /> AN EMPLOYERER TTO <br /> (100 Ogg), IN ADDITION TO THE COST OF COMPENSATION , DAMAGES AS PROVIDED FOR IN SECTION 3706 O <br /> 1 THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />