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JUL-24-00 TUE 1 : 15 PM M, D, F FAX N0, 91�->952 9535 P. 2 <br /> a7,124/2000 10:13 209467 <br /> AGE STOCKTON PAGE U3 <br /> I <br /> :JOB A06RESS: 5 _ (5 ! ORvd % Tk� LKfJt � PERM1hIIT SR#f:: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000 of Division <br /> 3 of she Btisiness and Professions Code)and my license is in full force and,effect. <br /> License# 7' v _n Expiration Date: <br /> Date: Contractor: p <br /> l ,( C ¢ �r l �/I'N 9/7 Y, r0 r <br /> Title: 2 <br /> Signature; <br /> Printed name: <br /> �f r A Nl' e � <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> Ihave and will maintain a certificate of consent to sell-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 <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, i <br /> for the performance of the work for which this permit is Issued. My workers'Compensation inqurance , <br /> carrier and fiCy,numbers are: <br /> Carrier �J � �( rQ POI1Cy Number: _ <br /> i <br /> I certify that in the perfofmance 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 Gallfomia,and agree that if I <br /> should become subject to the workers'compensation provisions of Seclan 3700 of the Labor Code,I shall <br /> forthwith Comply vnth those provisions. <br /> Date: Signature: <br /> 1 _ _ <br /> Printed Name: Y <br /> i <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL.,AND SHALL aU6JECT <br /> AN eMPLOYER To CRIMINAL PENALTIES AND CIVIL FINES UP rO ONE HUNDRED THOUSAND DOLLARS <br /> ADDITIONIN CTITO HE COST Of OF COMP NSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR N <br /> r <br /> (C-lt7lleenseboldfr),hereby i <br /> r^ <br /> authorize/pn./ I L or _04 �� �" Ui icons along),tv siyn this Ban <br /> L.,ulncountyWaa Pen»It Applfcaeon on my babel/- I understand this auhodzaHon Is valid rorqne(1)yearis limited to the work plan dated on ma front page Of this applioetion. <br /> I <br /> , <br /> i <br /> i l <br />