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JAN-21-2003 16:45 -,EDMATRIX FRESNO 559 264 7431 P.03/04 <br /> w v 1%0.b60.b <br /> sari Joaquin County Envlranmwm 11911111th 0008funm unit iV Weil Perna Apphtatiatt SupptMtetlt <br /> JOB ADDRESS: Lod S c w PERMIT SRS• �p 3L"5 3 <br /> l3 r �G 0 . <br /> LICENSED CONTRACTORS DECLARATION CD <br /> 1 horeby affirm that 1901 licensed under fie provisions 01 Ct*pter 9(cornrnmoing with section 7000)of Division <br /> 3 of the Business and Professions Cade and my license is in fUl farce and offs& <br /> License 9: 36 3 Expiration Date: — <br /> DOW. 1 /7-1 D3 Contractor. a i ,� •^,, - s..,� ,, i.. __ .._�. <br /> 81gra1ure: <br /> Printed nstee: , <br />` WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under ponelty of perjury one of ft►e following declarations: (CHECK ONE) <br /> I have and win maintain a certificate of consort to 0011-insure for workers'c ompens0on,as provided for <br /> by Section 3M of the Labor Code,for the performance of the work for which this penydt is issued. <br /> I have and will maintain workers'oomponseon Insurance,as rewired by Sec0n 3700 of the Labor Code, <br /> for the performance of tits work for which this permit is issued. My workers"compensation insurance <br /> carrier and polloy nurnbm are. <br /> Policy.Number: W 149-11 07;93 5' d1%. <br /> f certify that in the performance of to work for which this 1permit is issued I shall not employ any person in <br /> any manner so as to became subject to the workers'corrtponsation laws of Callforrmla, and agree that N I <br /> Should became subject to the workers'compensat on proMsrarss of Seaiton 3-00 of the Labor Code, I shall <br /> lortflwith comply with those provisoms. <br /> F Date: I 'LI Z-6-3 signatum: <br /> Printed Name: <br /> WARNING: FAl1,llRE TO SECURE WORKERS'COMPENSATION COVERAQE 15 UNLAWFUL,,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRINiMIAL PENALTIES AND CIVIL FINE11 UP TO ONE 1iUN17R110 T11DUSANID DOLLARS <br /> ($100,0MI IN ADDITION TO THE COST OP COMPOMTION,114119111119T,ATTORNEYS FFA,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 37Dd OFTHE LABOR COOK. <br /> 1 UTHORIZA110rN FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> (elgnatuto o1C.6771ieen3ad a.wh6thred rsprms erftare). <br /> hereby autlterize(print nfwhip <br /> tv sign thio San Joaquin County Wall Permit Application on my bahalj. I undermbsnd 11I99nuft rlxorion 19 Ybbd lent <br /> a+e(1)year and Is tlmited to the work plan dated on the frarrt page old appilt:aticn. <br /> Ii~�a t 11lI <br /> po l"'A TCr.), t7c� pec raa1=au.1 `1 T]I 1 Hur)Me7 AC!A T carate-ra�.ar r <br /> ti <br />