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S-01-199S 4: 17AM FROM P. I <br /> RC1 /J 201 ?C 27Ao vEA,R H 7EH11 ES No 69C2 D 3/5 <br /> Ssn Jollqutn County fevironmerrtttt tfealttt Ssrvfcas,Ustit IV WON Permit Application Supplanw�,t <br /> .JOB.ADDRIESS: Carne g, N.�twera.Qavy�E.Flora. PERMIT SRO, <br /> LICENSED CONTRACTORS DECLARATION (LCO) <br /> !hereby affirm that I am licensed under the provisions of Chapter 4(commencing with Soo'cin 7000)of Division <br /> 3 of the.Busines/s�.aad,pratessions.Coat and.my license is in full force and effect. <br /> 1 License 9:^ C�C� i� _ Expiration Oats: <br /> Efate: _&- 00 Contractor: 5' f1 1 !! <br /> SigtlsWrr: �� A�''/ <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under.penaity of perjury ons,of the following declarations: (CHECK ALL TMT APPLY) <br /> I nave and will maintain a certificate of consent to sell-inure for workers' oomperisatiort, as provided for by <br /> Section 3700 of the labor Code,for the peAormance of the worst for which this permit is <br /> issued-1 have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Coda, <br /> for the performance of the work for which Utis permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are. <br /> Carrier:. 4Policy Number: :!'�?.�`3� --Q!5-el j <br /> i <br /> } I certify that in the performance of the work for which this permit is issued. I shall not employ any person in j <br /> any manner so as to become subject to"workdrs'compensation laws of California,and agree that it I <br /> should become subject to the workers'compensation provisions of Secdon 3700 of the Labor Code, I shall <br /> 1 forlhwith complywith those provisions. <br /> oats: 5rgltalturw: �� ___ <br /> Priltted Name: ­ba Yf r <br /> WARNING_FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER:TO.CRIMNAL PENALTIES AND CML FIND UP TO ONE HU14DR rD THOUSAND DOLLARS($104,090.),IN ADDITION TO THE COST OF COMPENSATION,INTEftST,ATTORNEY'S FEES,AND DAMAGES AS <br /> pRovIlDED t-OR IN SECTION 3705 OF THE LABOR CQUE. � <br /> a:,?.t ✓i!� F `5�. (C--5�7-Ilcensed aut orhwd mpmaontativol hu"by. <br /> is sign:this San Joaquin County Weir Permit Appfketlan on my gehapt. I undemLvid this authorization Is valid for <br /> one,(1),yey and is limited to the work_plsn datedon the frbmt psge.of flee applie!Wn. <br />