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09/ 05 / 2002 es : 56 2094673 ` 9 AGE STOCKTON -- PAGE 02/ 02 <br /> SEP - 3 - 02 WED 5 : 25 AM M, D , h. FAY. N0 , 916 _ 4 9558 P . 2 <br /> HP/26/ 2a02 15 : 27 2094671119 <br /> AGE STOCKTON r•r.«a� n <br /> r u , <br /> cul // / Z I NINE <br /> 11, ILIA. <br /> 00 009 <br /> JOBAQDRESf3; 53 �wrrvau� -. - =_ - ate= <br /> LICENSED CoNTI7AGTORS DECLARATION (LPA <br /> rwlslona Of Chapter 9 (COntmencing with Section 7D00 Of Division <br /> 1 hereby effirm that I am ttcensed under hand MY <br /> littanse is in fun force and effoet . <br /> 9 of the 6ustn/eta and Professions Code) r �Q <br /> License E) Pkegon Date: _, C� <br /> Data' "" 3 ALL- <br /> printed <br /> Printed name: <br /> G �. 1 <br /> WORKERS ' COMPENSATION DECLARATION <br /> I hotebY affirm under penally o1 perjury one of the following d olaratbns; (CHECK ALL THAT APPLY) <br /> I have and wi ) maintain a cenlfieate of oehsehi to self•insure for workers' compensation, as provided for by <br /> Secon 37Do of the Labor Code, for the performance o1 the work for which 1I perrnR is issued, <br /> ti <br /> c I have and will maintain workers' compensation insur000 , as required by Section 3700 01 Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' Compensation inswance <br /> carrier and poncy numbers arc: <br /> Policy Number; 11 - 07 <br /> Carrier: <br /> I certify that in the performance of the work for which this permit is issuad, I shtill 661 employ any person in <br /> any manner bo as to become subject to the Wprkera' ComPenSatipn ltlWS of California, and agree that If I <br /> should become subject to ins workers' compensation pravlsiona of Section 370D of the Labor Code , I shell <br /> forthwith comply will) those provision. <br /> Date: Signature : <br /> Printed Name : <br /> AND SHALL <br /> AN WARNING: FAILURE <br /> EMpLoyI U CR M NAl Pf:AI.YlES AND C VIIL FINES UP TO DNR hVNdRED JM©USAND PA LAf1evI�JECT <br /> D <br /> PROS DEO FIN AITION TO THE COST OF COMP <br /> OR DD <br /> 31U5 OF THE I A!50 <br /> rt COpEIDN, INTEREl7, ATTORNEY'S FEflB, AND DAMAGES PS <br /> __SIC 1f � 1 <br /> i ` A C (I license holder), hereby <br /> authvrtze of D '� _loonsutGnp). +oslgnthis5an <br /> Joaquin County Will Permlt Application on my behalf. I understand Ibis authorixelion 19 valid for one ( 1) Year <br /> and is limited to the work plan dated on the front page of thio applle""m <br />