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>a-t�s6 s: i8arn FROM P. 2 <br /> ` 4. r LVv.. iJJ 1i vi l4 L.l�� t� l�'V 11ICV4�vl rs y J '.M V' V•!jV � r�4 <br /> stn coa»ty Enviro o"tat Fl.attn Sa VMOS,Uftlt!v weu PomitsQ4 -t' <br /> Application Suppkment <br /> JOB ADQRESS: e/v 1 X19. PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATIONL{Cb] <br /> I hsrrlby sffsrm that I am licensed under the pmviskris of Chapter 9(tommencing Vita Section 7000)o!Division <br /> 3 of the auslneaa and PMf $3kMs Code and my 3icense is in tull furca and effect_ <br /> i t fcsrtae Expiration t,we: j-Z <br /> c n <br /> Prim reme; i S"-4 <br /> WORKERS' COMPENSATION DECLARATioh <br /> I hemby affirm under true silty of perjury one of the fakywing degaratmns: (CHECK ALL THAT APPLY) <br /> 1 have and will maintain a ceruftate or consent to salt-insure for workers" pbrssation,$a provided for by <br /> SecWn 3700 Of tltG l.atsor Code,for the perforrnancm of the work for which this pernn4 is issued. <br /> ' �Rcvq and w#t maintain workers'comperssWAvn Insurance,as required by Section 3700 of the Labor Cod#,, . <br /> far the performance of the wont 10,whiCh V"perrrrlt is issued. My worKers'compensation mrurance <br /> carrier end p0cy numbem are: <br /> t Certify that in t►te portWMe tCe of thre Wo*for%Yno this permit is issued. 1 Shatz not em <br /> ploy._._any frt mer so as to ttctamesUto w to the w0AWS,corny ensation taws of C.adfamla and any person in <br /> should become subject to the workers'�pensation P V^ovisiorsa of 5 � agree that if t <br /> forthwith comply with those previslons. ecttott 371)0 of the Labor Code, i shall <br /> Date- 7 Signature.- <br /> PAnted Marne:__.: i/d <br /> WARNING.FAILURE TO SECLWM W QgMRS'CRIMPENSATION CCMMRAGE tS UNLAWFUL,AMD*HALL SUBJEOr <br /> AN EMPLOYER TO CRIMINAL i°'t NALTIE3 ANO Gnat.PINES UP TO ONE NUNDRED THOUSAND flt7l.t./AR8 <br /> (x100,WG.�.IN At3iItTIOM TO THE COST(W C{al -jNSATION,MTEWSY,ATTORKEY'S-F'EM AND DAMAGES AS <br /> PROVIOM FOR fN(SECTION 3706 OF TIE L50R CODE. <br /> � (C.37 Newnevd euttwrbwd rSDKsirttalt"),hereby <br /> +asfttrarlsv__ C y 4 <br /> C4- <br /> to slpn this San Joaquin County WQ Pwmft Appftrtinrr err my lfsttati. t ssrsaerstanrf tAts es�ttsvrirat;or, r;lid for <br /> L!"I'l <br /> a)gear arra is UftiAk t W they work Pias dated on-the hone pWq of this appii�auoo'. <br /> ,11: Ott <br />