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dJ�N-02-2009 TUE 01;15 PM Pr Exp I o r a t i on, I nc, FAX No. 91 4 4206 P-005 <br />06/02/2069 12:45 18314` . 45 OFFICE DEPOT PAGE 85 <br />Courity Environmental Health .":.: <br />P, �. <br />Joaquinson <br />1 <br />JOB ADDRESS:r %AY+�PERMIT SR 9 <br />LICENSED CONTRACTORS DECLARATION <br />(54imnwincingwith SOC401, <br />1 I 1 Of <br />I h"aby affirm that I am iicansw under the provisions of Ch"r 9 <br />DMsion 3 of the Budness and profesgons Code and MY 1110017198 Is in Nil force and effec' <br />License <br />contractor.- <br />OR r r r <br />r. + <br />I hereby affirm under penalty Of P$4urY One of the following <br />to <br />self-In6ure for woftre compensation. as <br />provided for by GeWOn !'! Of .. Code . performance of the work <br />permit is issued. of the <br />I have + Wig maintain workeW compensation <br />a +. ..21+Iftst T+ Polley Number <br />i Certify that In the <br />pgrformgnce of the work for whlch this +_ <br />MIt Is Issued, I -shall not employ any <br />pmon in any manner so as to bOCOMe SUPOCt to the WorkerWCompensation <br />agree that if I should -become subject to workerW compensation provisions of Section 3700 of thel <br />Labor Code, I shall forthwith comply with those provisions. <br />+ DOW ♦L..r..i.� �,I <br />Print Name: <br />AIV <br />WARNING: FAILURE To SECURE WORKERS' COMPENSATION COVERAGNIS UNLAWFUL.AN0814ALL SUBJECT AN EMPLOYRATO <br />CRIMINAL PENALTIES AND CIVIL FINES UP TO 410%DW. IN ADDITION TOTH19 COST OP COMPENISATION, WIVROST. <br />ATTORNE-rS FEES, AND DAMAGES AS PROVIDED FOR IN SECTWN 3"0 or- THE LAWR cooiL <br />sign this San Joaquin county Wag POMR APPlIC41110n On MY beh8lf- I uOdOrstand thft authorization Is valid <br />i',,ibrorm,yaw and is 11mited,16 the Work plan 4*60h the tMntpI%9a or this application. <br />r -e,[ <br />gm*2"9 'iioloz YYELL I`WWPRP <br />