Laserfiche WebLink
San Joaquln County Environnrentsl Health Departnrent I Init N Woll Permit Appketion Suppkrnent <br /> JOB ADDRESS: 2801 West Lane Stockton PERMIT SRS: D 0 S U-i <br /> LICENSED CONTRACTOR4100 <br /> CLARATION (LQ <br /> I hereby affirm that 1 am licensed under the provisions of9(oommencing with Section 7000)of Division <br /> 3 of the Business and Professkm Code and my license iorce and affect. II <br /> License*_.��( V5 Exp <br /> Date: � _ �%l t�lInc-- <br /> . <br /> t3 nature: Title: oto S G L1 <br /> Printed name- l S <br /> WORKERS'COMPENSATIOb DECLARATION <br /> I hereby affirm under penally of perjury one of the following s: (CHECK ONE) <br /> —I hoe and will maintain a certificate of consent to aeff4naw re for w+orMW compensation,as provided for <br /> by 5ecfion 3700 of the Labor Cock,for the performance of work for wwhich this permit is issued. <br /> _I have and wM maintain workers'compensa3ion Insurance, s requhed by Section 3700 of the labor Code, <br /> for the performance of the work for which this permit Is My workers'compensation Insurance <br /> carrier and policy numbers are: f f <br /> Carrier: Policy N ereler... 86 D� 1 <br /> 10V*that in the performance of the work for which this im rmit is issued, I shall not employ any person In <br /> any manner so as to become subject to the woftm'compe nsation laws of Califomia,and agree that ii I <br /> should become subject to the workers'compermattan offoo of the labor Cade,I stall <br /> kw tw th comply with those provisions. <br /> Expiration DoW. 9�1�f 31roah"R <br /> Printed Monte:. <br /> WARNING:FAILURE TO SECURE VMMRKEW '0 IIPE1-1IITI DN CNERAGE IS UNLAWFUL„AND SHALL SUBrECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CM.t�iEB UP ONE HUNDRED THOUSAND DOLLARS <br /> (:100.090.11,IN ADDITION TO THE COST OF CO ATiON. ,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> FOR 0 THAN C47 SIGNING PERMIT APPLICATION <br /> �'Zzr"I, oflC-W licanasd aullwriasd ralp nsenta thol, <br /> lrant+yau0hariraa <br /> W-.Rnw*L----AathQnX Minlin Se for Geolo 'st URS Co oration <br /> to sign this San.IowpAn Cowdy WW1 Permit Applicaaoe on my behalf. I undo Mot rd this millowkwilcon Is vagi for <br /> one(1)year and Is Ilrrrtbd to the work plan rlatied on the hos poop of#ft applkaftm <br /> 849-0210 <br /> i <br /> ®294M-Wl <br />