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JUN-3-2002 04:53P FROM: 70:7723571 P:3'3 <br /> i <br /> 14 0 <br /> PWN a " <br /> xNZ <br /> San Joaquin Cour <br /> - -w•so.wnrt iv welt Permit Application Supplement <br /> JOB ADDRESS: lq Z T-G N. 49 <br /> PERMIT SR#: <br /> LICENSED CON7RACTORS DECLARATION LCD <br /> I hereby afTxrr,that 1 am licert9ed under the <br /> 3 of the 8usrness and Processions Code end may license fis in Chameter gll am( and effect. <br /> with Section 7000j of Division <br /> - EXpiratkut pale: <br /> Gate: oa Can <br /> Signature: <br /> Title: <br /> Printed name:s / X64 <br /> WORKERS'COMPfNSAT10N DECLARATION <br /> 1 hereby affirm under Renalty or pe"one of the rdbwin d <br /> S adaralktns: (CHECK ALL THAT gppLY) <br /> ---I havv and wol maintain a Certlllcate of catsent to self4nsuro forworkero'carripensati� <br /> Section 3700 of the Labor Code,ror ute pwf of the work for which this i;issued.provided for by <br /> ✓t have ertd w�l m�tai» � Pe?nd is issued. <br /> for the end wrrt�pi IIIc wait for which ttds 'n '84� by Seer'3700 of the tabor Code, <br /> Caller and poiit:y umbers are: pwmlt is Issued: My workers Compensation insure <br /> Caller; <br /> Policy Number. /1,_'z' '5—d <br /> .` <br /> 100" <br /> tact in the perfpmtan0e of the work for which this <br /> any r so as to become subject to the workers•any �Issued.!sheQ not ernpby shy person In <br /> Should become suNaa 10 the workeW setion am of Cai'ikrrtia,and agree that if I <br /> forthwith Comply wkh#me t iara.�Pensetion provisions of 80060n 3700 of the Labor.QW9,I shall <br /> Date: <br /> signature: z <br /> Printed Rome: <br /> WARNING:PAURE TO SECURE WORMERS'COMPENSATION COVBRAOE!.9 UNURWt=tIL,AND SHALL SUBJECT' <br /> AN EWLOYER TO CRIMMAt PENALTM AND CML 1rf1+MS IIP To ORE HUNDRED WR)L.AN DOLLS <br /> (5100,000.).IN ADDITION TO THE COST Cw GOMPI±NSAno*,IN'T'ER NE ATTORNEY'S REAS,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3799 Or THE LABOR CODE. <br /> a , !4� �) sa4 <br /> {C�7 Kcww*d autho*md rePMentativoj,hereby <br /> authorize � <br /> to sign this San Joaquin emmty Welt Permit Apphcetion on my behalf. 1 understand this autherLution is valid for <br /> elle(1)year and is limited to ft work plan dated on the front pqp of this appticattQn. <br /> ,ILV-2000 I MI <br /> ' n <br /> MAY-20-2002 MOAN 11:33A M I0: PgGE,1 <br />