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62/23/2801 13:53 _q 'ills AGE STOCI 'h' PAGE 83 <br /> San Joaquin County Onvlronmental Health Services,Unit IV Wali Permit Application Supplement <br /> JOB ADDRESS:�� o (Z� PERMIT SR* <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby gin.. that t am Iicensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Sualneas and Profasslona Code and my license Is In full farce and elFact, f <br /> License#: G,2?,,- 1 _-- �Xpim don Date. 1 Z31-&/Q Z__ <br /> Date: <br /> Signature: Title: <br /> Printed name_ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHI=CK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for by <br /> Section 3700"of Iha Labor Cade,for the performance of the work for which this permit Is Issued. <br /> I have and will melntain workem'compensation Insurance, as required by Section 3700 of the Labor Code, <br /> fior the performance of the work for which this permit is Issued. My workers'compensetfon insurance_ <br /> carrier and poW-y numbers are: <br /> Carrier, , omPQ Policy Number: IT <br /> I car*that in the performance of the work for which this permit is issued, I shell not employ any person in <br /> any manna so as to become subject to the warimrs'compensadan Ism of California, and agree that if I <br /> should become subject to the wwkers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with&mae provisions_ <br /> Date: f 319nature: <br /> Printed Nerne- <br /> WARNING:FALURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND$HALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENAL'"ES AND CIVIL FINES lir TO ONI~HUNDRED THOU34NO DOLLARS <br /> ($1100AN-).IN ADOMON TO THE COST OF COMPENSATION,INTEREST.ATTORNEY'S FEES.AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR GaDE. <br /> < C47 licensed nuthartzed representrdwl,hereby <br /> authorise • <br /> to sign this San Josquln County iNe11 Permit Apptltstlon on my hehoff. I understand this authaftetinn Is valid for <br /> ane(i)yew and is IlmlEed to the week plan.dated an the front ps0e of this appilcaon. <br /> X17 20M!MI . <br /> Z/Z a6ed `Z4 9L w-£z-4ed •`ZO£0 64£ SZG `'auI 16uTIsal I buiTTTjO 66ajo :As qua£ <br />