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Z0'3Jtid Z0£0 £T£ SZ6 <br /> BT:ZT 00, 0Z 63S <br /> �- -w� aL✓L07✓Ok1C <br /> 40:ST 00. BT d95 <br /> F�DlalybtrflinrRantAltiealih arvlcec,llhlliff; bl Ps( rqtJtA6pIIcx�lon Sw)1�fafll g(P� <br /> Aa <br /> LICENSED CONTRACTORS DECLARATION (L90) <br /> I hereby affirm that I am licensed under the provlslons of Chapter 9(commencing with Section 7000)of Dlv1si0n <br /> 3 of the Business and Professions Codeandmy license Is in full force and effect_ <br /> License#:_ &I ��I��6„f Expiration Date:_/ P,,/ <br /> Date= 4 ��� Contract <br /> Signature: Titre: r <br /> L C?�Dr'Y4' !JY/lI �fi1�'.atY <br /> Printed name: tom,/[f%O � jo.,Ocw c <br /> WORKERS' COMPENSATION DECLARATION <br /> ( hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> Xneve and will maintain a certificate of consent to selftinsure 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 /> I have and will maintain workers'compensation insurance,as required by Section 3700 Of the Labor Code, <br /> for the perlormanco of the work for which this permit is issued. My workers'compensation Insurance <br /> carrier and Poo6cy numbers are: <br /> rany <br /> rrier. Eon& Policy Number. _ `fS 000I-4*-r <br /> certify that In the performance of the work for which this permit Is issued, I shall not employ any person in <br /> 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: �Zo/O� Signature: //+1,,rry <br /> Printed Name:_ Qowu/l�f' _ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYERTO CRIMINAL PENALTIES AND CIVIL FINE41 UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST.ATTORNEY'S F"S,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 9706 OF THE LABOR CODE. <br /> (CST Ileansed auth6riwd repeeaontatival,hereby <br /> authorira RgN,�c;share oae�-}- �, „ . -r -L- e,*A' r RO-K-e- <br /> to sign this San Joaquin County Wall Permit Application on my b6II I undsratend this suthormsdon is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> 5-17.20001 MI <br /> E0 3%dd Mnn-ij Hi4r. <br /> Z0iZ0'd Z0£O£T£SZ6T O1 9O6P ZS9 OTS 3r016d 34in3- d.dl ad 6£:OT 00, OZ d3S <br /> ZrZ aced `LE II 00-OZ-dag `ZOEO EIC 9Z6 ` 'cuI `6uTySei g 6utTT7,l0 66aJ9 :lig ;uaS <br />