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0 <br />6 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Suppst­,,A­tat <br />JOBADORESS: PERMIT SRO <br />5foc. k* -n I C A - <br />I hereby affirm heat I am licensed Under the provisions of Chapter 9 (Commencing with Section 7000) of <br />Dtvision 3 of the Business and Professions Co0e and my license is in full force and effect, <br />License # Exp Date <br />Date Contractor <br />Signature Title LffzAnQ,-J HAOUAi�.6X <br />RW'4'-V <br />�t . ivagum <br />WORKER'S COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations (check one) <br />I have and will maintain a certificate of consent to self -insure for woftrV compensation, as <br />provided for by section 3700 of the labor Code, for the performance of the work for which this <br />permit is issued <br />I have and will maintain workers' compensation insurance as required by Section 3700 of the <br />Labor Code for the performance of the work for which this permit is issued My workers' <br />compensation insurance carrier and policy numbers are <br />AMIFO-ttA-1 )MTEAf,4A,11i*J4L <br />Carrier:�r_t 1,IAJIE.% , -Policy Number <br />I Certify that in the performance of the wo* for which this Permit is Issued, I shall not employ any <br />person in any manner so as to become subject to the workets'compensaton law of California, and <br />agree that it I should become sAbject to wo(kers'compensatton provisions of Section 3700 of the <br />Labor Code I shall forttrmth comply with those pro bions <br />Ex p� Date: Signature: A- <br />PrintName- 11goo CILA��F"_b <br />WARNING FAILURE TO SECURE WORKERS'COtAPENSATtOft COVERAGE 15 UNL^wFuL, AND SK*LL SUBJECT AN EMPLOYER TO <br />cRivitiAL PENALTIES AND CIVIL FI#4fS Up To $100,004), IN ADDITION TO THE COST Of COMPENSATIork INTEREST, <br />A rTORNEY'$ FEES, AND DAMA(ae$ As, PROVIDED FOR IN SECTION 3706 Of THE LABOR CODE <br />tl I T10 N FOR OTHER THAN C-67 SIGNING PERM17 APPLICATION <br />� <br />(signature of C-67 iic*ns" aut:mea zrepresentative), <br />hereby authorize 1p(int name) <br />sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br />for one year and is limited to the work plan dated on the front page of this application. <br />