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09 / 05 / 2002 08 : 56 209467 '9 A6E STOCKTON PAGE 02 / 02 <br /> SEP - 3 - 02 WED 5 ; 25 AAM M, D, FAX 110, 916 „ j2 9558 � � uP . 2 <br /> AGE 5TOCkTON <br /> nFlz6/ 2002 15 : 27 2694671118LL� <br /> ,- Y, . _ .'.. _.. -� . ' <br /> LICENSED CONTRACTORS gECLARATION WCrV <br /> h . <br /> 1 hareby affirm that I am acensod under 0A prar8lons of chapter g (commanGng <br /> with Section 7000 01 Div alon <br /> 9 of the Business♦ end Professions Cod#) and my fa�nse is in fyn foraa and effaet <br /> O3 <br /> _ <br /> � a / pxpitsUon Date: . D � � d <br /> 60 <br /> Date: <br /> 3 - d Z_ Contractor ! <br /> Sighature: � } <br /> G 2 -1 <br /> Printed name: ' <br /> WORKERS ' COMPENSATION DECLARATION <br /> I hatiiby affirm under penalty of perjury one of the following declaralion5: (CHECK ALL THAT APPLY) <br /> As <br /> Shove and will eol on 3700 01 thlD ILabor Code w h parterrtmance Of the work foSe'folitSure for rwhichthis permit Is Issued. Jded for by <br /> he Labor <br /> I have and will maintain workers' compensation insurance , ea 1eav'worksrs'red by Compensationpinsurance Cade, <br /> for tha performance of the work for which this permit Is issued. My <br /> Carrier and policy numbers arc: <br /> ��Sb ,aN� Poilcy Number: <br /> Cartier: —^ <br /> I oeril y that in the performI of that work tot which this permit i9 issued, l Shell nOl employ any person in <br /> any manner so ea to become avbject to the workers' compensatiptt laws of Csiifornia, And agree that if I <br /> Should Decome subject to 109 workers' OOmpon5allon provision~ of Section 3700 of the Labor Code , I shall <br /> forthwith comply with those provision9. <br /> Date: Si¢ nature : <br /> Printed Name: <br /> WARNING: FAILURE To SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, AND SHALL SVSJECT <br /> AN EMPLOYEK TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAt10 DOLLARS <br /> 1151001000-)4 IN ADDITION TO THE COST OF COMPENSATION,DCODEINTERE!!T, ATTORNEY'S FEEti. AND DAMAGES AS <br /> PROVIDED FOR IN 550100, 3146 OF THE 1 A _ <br /> (C_57lieanaaholderj, hereby <br /> authorlke D <br /> of d . . iasrror� fni[© III (consvtting), tesignthlsSan <br /> b <br /> Joar♦uin County Will Permit Application on my <br /> •hatf. 1 underhand this authorixslton J9 valid for one 0) Yaat <br /> - and is limited to the work plan dated on the front 0490 of thio apPllcsUom <br />