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1'li_6l YO :3 na:a'i 91GL'L'10� t':fdf • 1'A617 rrt U; <br /> San Joaquin County Environmental Health Department Unit IV Well f crmit Application Supplement <br /> JOBADDRESS:_,.1�; A A PERMIT SR#: 6640N) <br /> LICENSED CONTRACTORS DECLARATION (1- D <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Profess' ris Codr.itnd my license is in full force and ffect. �//� <br /> License#: ` 1 v L� Exp t'on Date; �_ lJ <br /> Date: nr <br /> �� D _Contra tor:_ Vy.�`��' <br /> 111 \ <br /> Signature: Title: <br /> Printed name: � 5 :_ <br /> — <br /> WORKERS' COMPENSATIC 1 DECLARATION <br /> I hereby afGrrrr under penalty of perjury tine of the following declarations; (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for <br /> by Soction$700 of the Labor Codo, for the perforntance of the work for which this permit is issued. <br /> I have and will maintain workers' compensation insurance,as required by Section 3700 of the I abor Codc, <br /> for the performance of the work for which this permit is issued. My workers'compansation Insurance <br /> carrier anipolicy numbe, arc: !J�� <br /> Carrier: G c Poliny Number: � V <br /> I certify that in the performance of the work for which this permit Is issued, I shalt not employ any person in <br /> any manner co as to become subject to the workers•'compensation laws of California, and agree that if I <br /> should become subject to the workers'compense.on provisions of Section 3700 of the Labor Code, I shall <br /> forthwith romp with those provisions. V <br /> Date: oSignature: <br /> Printed Name:- <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,A D SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (ST00,000.), IN ADDITION To THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,ANO DAMAGES AS <br /> PROVIDED FOR IN SECTION 370G OF THE LABOR CODE. <br /> THORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, <br /> ofC-5 lin ed authorized repre�ontativa), <br /> hereby authorize(print namal�S,x� _arm.m <br /> L <br /> n this San Joaquin County Wnll Permit Application oh my behalf, I undo tend this authorizadon is valid for <br /> f)year and Is Ilmited to Elio work plan dated on the front page of this appllcagon. <br /> 17.IMI <br /> FRI n£t 28 (1:1.12.\ NO 5: 2"1 01002 <br />