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[ San Joaquin Cunty Envirnnminntal Health 3etrvleos{,Unit�N Weil P¢imit ApplEcaUAn Suptf(cme/nt <br /> JOB ADDRESS:o <br /> i <br /> LICENSED CONTRACTORS DECLARATION <br /> I heroby affirm that l am licensed under tho provisions of Chapter g(commencing with Section 7900)of Division <br /> 3 of ti,a Business and Professions Code and my license is in full force and effeciL <br /> Lk4nsa �Q ZZ EViration Date: (,Q <br /> Date—Contractor <br /> { Signature: r ,�_Tif., l tri <br /> Printed name: LI/4f/' _ <br /> WORKERS'COMPENSATION DECLARAMIN <br /> thereby affirm under penelty of perjury one of the fonowing declaratlons: (CHECK ALL THAT APPLY) I <br /> _I have and will n alntain a uumificate of wrisant to self-insure for workers'compensatiot P.as proVlUod for by <br /> Saction 3700 of the labor Coda,for+he performance of tha work for which this permit is issued. <br /> f I have and will maintain workers'compensation insurance, as required by Secficn 3700 Of the Labor Code, <br /> for the performance of the work for which this patmit is issued. My workars'compensation insurance <br /> Cerner and policy numbers are: <br /> i Carrier J_. f u— Policy Number. Y8 Lo 't <br /> 1 certify that in the performance of the wont for which this permit is issued, I shall not employ any person in <br /> Oily manner So as to become sUtject to the workers' oompenUtlon IawS of California.and agree that If I <br /> should become subject to the workers'compensatlon provisions of Section 3700 of the labor Code, i sftall <br /> forthwith comply with thosa provisions. <br /> Date: Signature: <br /> Printed Name: <br /> WARNING: FAILURE To SECURE WORKFRS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> j$100,000.),IN ADDITION TO THE COSTOF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS I <br /> PROVIDED FOR IN SECTIIONN31080FTHE LABOR CODE. <br /> J111o41rr, 14 �.yC,� Q.-1 �J.�i�. (CC-5�7licensed authorized rreep�r�@� ritAllYR),hettlly <br /> j authorize ✓1 11(7 (.5 O N y�[ y.Tr>y re� <br /> Ito sign this San Joaquin County Wall PermitApDilcstlon on my behalf, t understand this authorittaeen is raid for <br /> one(t)year and Is limited to ft work plan dated on tho front page of this app!lcallw, +I <br /> I <br /> 5.17,2WOI MI �J --,.J <br />