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Salt JoaGiio: ;vans cBnvlzronrqental Vaal : Ser Acas, Unit JW NJni1 7erm3t Appimucmation Su,{3ferrer,3 <br /> LICENSED CONTRACTORS DECLARATION LIQ <br /> I hereby arFrm that I am Iicansed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and Protesslans Coda and my license is in full farce and elfea. <br /> License L Expiration Date: <br /> Date; Contractor r <br /> Signature: nn Title' <br /> Vu <br /> Printed name: W <br /> WO KERS' 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 cartlficale of consent to self-insure for workers' compensation, as provided for by <br /> Sectlon 3700 of the Labor Cade , for the performance of the work for which this permit Is Issued- <br /> 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 ar/e�: <br /> Policy Number* r} ii^ P) 60 <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 California, and agree at if 1 <br /> should became subject to the workers' compensation provisions of Sectithat <br /> on 37 of the Labor Code, I shall <br /> forthwith comply with those provisions, <br /> Data: til -7cl t Signature_ <br /> �" Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 19 UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL, PENALTIES AND CIVIL FINES Up TO ONE HUNDRED THOUSAND DOLLARS <br /> (5loolboo-)t IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, <br /> k C47 licensed authorized rapmventW"), harshy <br /> authorize r <br /> to sign this San Joaquin County Wall Parinit Application an my behsif, I understand this authorization Is valid far <br /> one (1) year and is limited to the warty plan. dated an the front page Of this apPltcallon- <br /> Sa17-2000 / MI <br />