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Son Joaquin County Environmental Health CheporUnontinhiV Weill pinucatton S ptaartent <br /> , / t75S��1 " .0 <br /> JOB ADDRESS: 5a cv, VtR PERMIT SR#; Viellit <br /> OS �° <br /> j pDW'InC��D CONTRACTORS DECLARATION (LCD Y DY Svc <br /> I hereby afttri that I am limed under ths prrwt%lrurs of Chapter 9 f mmmeodN with Section 7 )of Cftvislon <br /> 3 of the Business and Professions Cute and my license is In hull force and'eflIect. , <br /> �} f <br /> Ltcensa�' ! �t� _.�r.�u.._ Expirat7onf3ate. � ----�—'--�-t.,x <br /> Date: - Cortsori <br /> ky r� x <br /> Printed name_ L Y '? 4t 1 <br /> WORKERS*RS`COMPENSATION DECLARATfON <br /> I hereby affirm udder penalty of perjury one of the following dedarafions. (CHECK ONE) <br /> _I have and will maintain a ceubficate of dent to Sel f4mota for worker;;`comparatakon,as prosided fa <br /> by Section 370D of the Lahr Cada,for the performance of the work for wh(ch this permit is issuad. <br /> I have and will maintain workers'compensFition mumu mco,as requirad by Sedw 3700 of the Labor Cade, € <br /> far put perfont ance of the work tar which this permit is issued. My workers' nsatkm insurance <br /> caner and policy numbers are_ <br /> Carrfar, PONCYNumber; <br /> I certify that in Lha performance of the work fear which this permit is issuad,i shalt not employ any portion in <br /> arty mannan so as to became sublieed to the workets'co tion laws of Caltforrim,and agree that if I <br /> should become strbjad in the w-Drkens'componazation provisions of Section 3700 of Use Labor Code,I shall <br /> forthwith com*wain those provisions, <br /> J I <br /> Expiration Date: Signature <br /> Printed Name. t r I k l <br /> WARNiMG:FAILURE TO SECURE'ArORKERS'COMPENSATION COVERAGE l$UNILAWFt9&AN1D SHALL SUBJECT <br /> AN EMPLOYER TO CRIONAL PENALTIES AND CIVLL.FINE UP TO ONE HUNDRED THOUSAND DOLLARS <br /> !fTitOkDW.I, IN ADDITION TO THE COST OF COMPENSATION.INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3796 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPUCAT'ION <br /> laignature aiC-57 l/ica'ri%oil amkhorlxt-}representative), <br /> hereby aadhortm(print <br /> to sign this:Sat JoagWn County Writ Permit Application an.my 68htaW i understarid this authorization is valid for <br /> ane ft'.)year and M limited to the work plan dated ort the Iron#Pegg of this appOreban.. <br /> 5�4,-0fG I of <br /> Ffft)2e }41 <br />