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01/05/2001 16:13 20946� �a <br /> f:.GE STOCKTON PACS' 02 <br /> FOIS31) <br /> JoaquinCounty Environmental Health Services,UnitIvWelt Permit Apptleatian SupplementIy-M Th%Aki7fw RaijD PERMIT SR#: ZSdODRESS: co I c <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 8 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license Is In full furca and effect- <br /> License#:�,-7 its/6� - _Expiration Date: <br /> Date: <br /> 1' Contractor; <br /> i p�f /Jia a <br /> is iture: Title; <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> I 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 are: <br /> L Carrier: Pi Policy Number: V S woo � T�t <br /> �� <br /> 1 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 that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> 3 Date: Signature- — - <br /> Printed Name: _ f <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP To ONE HUNDRED THOUSAND DOLLARS <br /> ,IN AD SECTION 3N08 OF THE LABOR SATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED <br /> r <br /> V I � /j� _ (C57 licensed authorized representative),hereby <br /> authorize, Cv Z ll A F Alz e GT 'r A <br /> to sign this San Joaquin County Wall Permit Appitcatlon on my behalf- 1 understand this authorization Is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 6T7-2000 I MI <br /> 6/6 86ed fIC:4t io-S-uef`•Z0E0 BlE 9Z6 `• 'cuI `6uzlsal g 6uzTTTJO 66GJC :40 }uag <br />