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� Sart Joaquin County Environmental Health Servl unit IV WeH Permit Appllcation Supplement <br /> JOB ADDRESS:—S, JoC Ilt I` £R iT SR#:_ (of) <br /> i <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirrn that I am licensed under Iho provisions of Chapter 9(commenting with Section 7000)of Division <br /> 3 of the Business and Professions Code and my[[cense Is in full furca an�dr effect. <br /> License 4: t0, T 7 tit 7- Expiration Date ! Q —3 r) — © 3 <br /> Dater 7 Contractor. <br /> r"J <br /> i{ Signature: '' TitloT: Yl 1 LN <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARA71ON <br /> I hereby affirm under penelty of perjury one of the fallowing declarations: (CHECK ALL THAY APPLY) <br /> _I have and wiil maintain a uLrtificate of consent to self-Insure for workers'compensation,as provided for by <br /> Saction 3700 of the labor Code, for the pertionnance of tha work for which this permit is issued. <br /> { I have and will maintain workeW compensation insurance,as.required by Section 3700 of the Labor Code, <br /> for the performance of the work forwhich this permit is Issued. My workers'compensation Insurance <br /> carrier and policy numbers are: i <br /> t t <br /> .policy Number: <br /> i <br /> I certify that in the performance of the worK for which this permit is issued. 1 $hail not employ any person in <br /> Any manner So as 10 beC.Ome SuD)ect to the wdrKers'Compensation laws of California, and agree that If I <br /> should become subject to the workers'compensation ptovlsions of Section 3700 W the Labor Code,t shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed Name; <br /> WARNING:FAILURE To SECURE WORKERS'COMPENSATION COVERAQE 19 UNLAWFUL,AND SHALL SUBJECT f <br /> ( AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE CO3TOF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS 1 <br /> PROVIDED FOR IN SECTION 3106 OF THE LABOR CODE. j <br /> ' / It <br /> I, L c{6t��ICC / C- Q.-J f ("7 licensed nuthod2ed repr@5pntatly4),heirepy 1 <br /> authorfzcyL I; . /- <br /> O p 4 <br /> to sign this San JoNuin County Watt Permit ADDllcatior.on cry behalf. I understand this autbarizaUon is raid fm <br /> one(t)year and Is limited to the work Aran datad on the front page of this appllcation. <br /> 6+17.20001 MI ,_ .�.......JJ <br />