Laserfiche WebLink
- ----.i4i�,I." I <br />06/. '05 TLTE 14:21 FAX <br />. 002 <br />b1. rl4:311 <br />Wean Joaqunty viirrooynme I He Ith Department Unit IV Wel Permit Application Supplement <br />-A MWA rt �q�+►jcation SU[�p7lArll�nt <br />;an ,Jpaquin Coun A <br />JOB ADDRESS: PERMIT SR#: ,�J'yLJO <br />L ENSED CONTRACTORS DECLARATION (LCD) <br />�'(69TORS�CLARAT(ON (LCD) <br />I hereby affir s ovisions o apter 9 (commencing With ection 7000) of Divisi <br />3 of the Business and Professions Code and my license is in full force and effec <br />i h rp-by affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 f �Qeee qio' Professions Code and my 1ice11se60rM6€?t59t9nd ffect. <br />C I_XPLlanon Date: <br />n <br />S <br />Lor: <br />Title: <br />Printed name: _A-Av ���"COMP_ENgATION DECLARATION <br />WORKERS'COMPENSATIOTq DECLARATION <br />I hereby affirm under penalty of perjury one of the following declaratioq��epI %2VE) <br />I t rehy affirm under penalty of perjury one of tho foilowing declarations. 1 <br />_ I have and will maintain a certificate of consent t self-insureVfor <br />I t,a4tf $e�ti�itl �r8�q <br />by Section 3100 of the Labor Code, for the pe nt1anre off f1h ,, �r l'� Wtfic Ti r 6��tSc9ued. <br />I have and will maintain workers'-�com i)i� i ren ,r��r��g�i t$5t00�DQtc�f tta��a�tdCr <br />_ I hav W �fbnri�i� ��{ e a�e\vVl`lic�i I� rR� i s 4✓ $� ly dt npeti®atio»fr€31R4nce <br />��� Fa: <br />carrier an poi n � -� � j� E ,- �lj\(1[� <br />CArrl �: POW-191"itthl baLloJ,— <br />Carrrer: <br />t ceritli h plo n ecson in <br />I @Fier l>� tb�erbv�k�fdr ribfl t� l r4�it sSu �, ii�f� p,Tp eJT �ygrtpoPson <br />an fl? i l t�� bR�met�j t�ttD�tta�r ilc�r� ��1i9�tlr�ig' ons I'm 'WW"wiI <br />sho4+��rr31P11i3xttly ihl�r�b&fi�crT(§� S�tRfr4 �1r�h9dsS ecti9 of t e Labor Code, I sh <br />fr�rt�rRPtg�ialKlv�tlhf��I�Q���f3`ronS. r // � � /�''; <br />{ate: F.nuki7� <br />Pri rR#Ad*��Ril�s <br />FS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />�I IaS91��t1 CQIZG iAQfE1BWNt41 p 6ARE-S�UBJE <br />Qf�/ 7 f�iN�9JOl�FdIO;mN� H10Rd�1�L� 68� 1� �k*3 AS <br />W4 L C <br />1�4p RWLQ,fgMWMMATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES F <br />3706 OF THE LABOR CODE. <br />FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />N OR-OTTIEW THAN C-57 SIGNING PERMIT APPLICATION <br />�,,� �(signaiy�ra DKC 57 A' rTed authorized rarireaentativa), <br />i f e taut r sentatiy ), <br />ereby autiionze [print n3cnR) - <br />hereby authorize (print namtiolloil"IVundoorizatlon is valid in' <br />� sign this San JoarJultt County � <br />to sign tahiscSa & jfrni�ec�o �c�tea����t��p�l�i�g'Arp@�.k~ ;kM6d Stand this authorization is valid for <br />one �l) ar and is limited to the work plan dated on the front page of this application_ <br />8-29-02 1 MI <br />n6/28/2005 TUE 15:37 [TX/RX NO 64241 1a002 <br />