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Jun-05-01 07 : 33A P.02 <br /> 06/06/20U1 11:5u 9715-7366 LFR GRANITE BAS' F'AGt U` <br /> ,v701 f <br /> San Joaquin County Environmental Health Services,unit 1V Wen Permit Application Supplement <br /> DU 265e-3 <br /> JOB ADDRESS:. L/NCoL,V a-Et— .2� PERMIT SR#: QQ Sk <br /> LICENSED CONTRACTORS DECLARATION <br /> hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Plofrol eess,onsCode and my license is in full force and eeffect. <br /> License#: C,_t)- 1 /I-r+ 1 Expiration Date: <br /> Date: _ 1 _ Contractor. <br /> /Lx, Title:�r�d!"d 11 ^ / +5• <br /> Signaturo:_, <br /> Printed name: WA/S) 7k,44p, li / <br /> 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 cePoTicate 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 /> I 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: p rip <br /> Carrier: � Tr_( S r�,t�olicy Number. WC W O 1 l J <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 Califomia, 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:. b—SjE:O f, signature: <br /> Printed Name-. �Hi14 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANO CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (if oo,0oo.),IN ADDITION TO THE COST OF COMPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IIN/N SE <br /> C <br /> TIO <br /> N <br /> 37"OF THE LABOR CODE. <br /> �ll"d"� (signature*FC-67 Hameed authorized representative), <br /> nereby authorize(print name) lky lZ O>/� <br /> to sign this San Joaquin County Wen PermitAppileation on my behalf. I understand this authorization is"lid for <br /> one(1)year and is limited to the wont plan dated on the front page of this application. <br /> 5-17-20001 MI <br />