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San•Jampin Car011111entai Ifealfth 3isr%1C=,Unit lv well Pwmlt AppikelbW4SuPp4"*"t <br /> JOB ADDRESS- PERMIT SfW. <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby of trm that I am licensed under the provisions of Ctaapler 9 (=nrnwldrrg wed Sectiat►7000)0 DMIlion <br /> 3 of this Business and Prof"siona CODs end my Ilcense is 1n tuft force and e+fsn t. <br /> Ucen"A C- S7 717 ���- �aon t �0 3 <br /> oelt:; — —0 ConVuftr c <br /> Sl�taduee� 7ltte: � � <br /> Pring na�rtte: Q Q ��' <br /> WORKERS' COMPUNSA'nON DECLARAMN <br /> I hereby affirm rxrder pw*ty of per ury one of the foitowring dadeMlior= (CHECK ALL THAT APPLY) <br /> I have and will maintain a ceNflcate a zvnsent to seMnsure foe workers'cor'npems ow,as provided ftr by <br /> Soction 37W of lite Labor Cade.far the peftmencce of the work for whicfi this permit is issued. <br /> I have and 411 maintain worirem'mmoonsatign mutant e, e3 required by Sin 3700 of the L&W Code• <br /> for t4a performance of the work for which this plxmit is lsauad. tally wwkaw czrnpensslthsn irwex'ave <br /> carrier and policy n1004=1000'sa <br /> e /�W <br /> carrier!'f Q S Kck v Q d_Q Policy Number <br /> I certify that In the pw•formance of the work for which No permit is issued. l shat!not wnpicy any Pin in <br /> any rnwvw so as to beGomo subject to the workers'compan Vors taws of California,and 80me drat if I <br /> should bots me subject to the workerx'compensa0on provislo ti 3700 of the Labor Cods, I shall <br /> forthwith comply wdhrgum provisions. <br /> Dual: ��c3 C� 0 / Slprsalture- <br /> Primind Hamm: ra <br /> WARMHU:FAILURE TD aECUIIE W N ewer conireHSATION COV©%►QE is uNLAWFUL.AND*HALL SUBJ=T <br /> AN ENPLOI glq TQ CRtIYIINAL PeNALT1ES AND CIVIL RMeS Up To 01MEr HUNDRED Tl1OU3AIMQ gdLLAim <br /> ($1W,090.1,IN A001'tY N 7O THE COST OF COMPUMATION,IN'[SfiEST.4 TORNM Rhe.AMD OM644ES AS <br /> TRg"DED FOR IN SECTION MS OF THE LABOR C00E. <br /> yC,V licenoW authorised miomm rrarth.),hereby <br /> . autlsortar <br /> to sign this son Jeaauln County Woll Pwmtt Appllestlen on my halWE I understand Oft SUOU rIS"ar►is Valid far <br /> vase(?)yarr rand is lirnika to the wok plan dated an ted fmnt page aithis opplRvaori. <br /> S-ly.2t100/fife . <br />