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F 1 • <br />- <br />®en Joaquin County Environmental Hoolth Deportment Unit IV Walt P ormtt Application ®upploment <br />JOB ADD RF111111a: Wn2-0 A�vvpar-7' wy ___ _-- PERMIT 81W C034-3 <br />LICENSED CONTRACTORS DECLARATION O <br />I hereby Affirm that I am Ilcenved under the provisions of Chapter 9 (00m111arlcing with Ssctlon 7000) of oivlslarl <br />3 of the Business and Prufooslons Cade and my license Is In full force end offer, <br />6 License #: 7770 7 — �x IraNn Date � / V16�-1,�- <br />pate; r o Con acto <br />r � � <br />t9lanrtura; TINe� [� rtfi� <br />Printed name,oo <br />WORKERS' COMPENSATION DECLARATION <br />I hereby aMrm un0er penalty of pequrY one of the following decisrAtlons; (CHECK ONE) <br />have aril will maintain a cxrttficale of consant 0 sell -Insure for wrorkers' oompehaetlon, as provided for <br />by Becton 3700 of the Labor Godo, far the performance of the work for whioh this permit Is Issutd, <br />_ I have and will maintain worhors' oompensatton Insurunca, as required by 8ectlon 3700 of the Labor Code, <br />for the parfom,anco of the work for whioh this permit is leaned. My workers' cornpensetlon Insur+anoe <br />carrier and pallay numbers era; <br />Carrior �. Policy Number,7-fo - 7=36 :3 <br />I car N theft in the performance of the work for Which this pertrlt Is Issued, I shall not employ any parson In <br />any manner so as to become awbfect to the woricans' compenastlon laws of Gaitfnmia, and agree that If <br />should become sukpo to the wo*ars' oompensatlo provl2iona of Geatlon 3700 of the t,apor Code, I shell <br />forthwith =rnpty with those provisions, <br />[iMt1t; � �Ipnature� <br />Printed Nemo; <br />WARNING: FAII.URE TO $901UR! WORKER@' COPPEN&AMN COVEWE 13 UNLAWFUL, ANQ SNA" SUIWECT <br />AN EMPLOY10 TO CRIMINAL PfNAI.Tn15 AND CIVIL FINE8 UP TO ONE HUNDRED THOUSAND DOLLARS <br />IPRO1l(p pIN A <br />ADOR ITION TNTHE <br />COST OF TNI: t.ApCR COOSINTEREST, ATTORNEY'a FEES, AND DAMAGE'S A8 <br />TION FOR ,O'TMEA THAN C-87 SIGNING PERMIT APPLICATION <br />r "1 - <br />signature aft; -FT llosnsad awthorierad reprevents0vt), <br />hereby gWhork• (print <br />to sign this Bon Jaequin County Well Permit Application an my Whatf. I underntsnd this Authorltation in valid for <br />one (1) year and In Ilmtted to the work plan dated on the front page of this applicatson. <br />