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ear r v-. vv.. .v .W ,rJVVG <br /> 12;.E./2[rF?s md::dt� 91r,:1L10 :,1-c:IiR • I'ALiF <br /> s <br /> San Joaquin County Environmental Health <br /> -�Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:_10 S, �73T/!_t� PERMIT SR#: 7 <br /> LICENSED CONTRACTORS DECLARATION (LCb <br /> I hereby affirm that I am licensed under the provisions of Chapter g(commencing with Section 7000) of Division <br /> 3 of the Business and Professi ris Codr.and my license is in full force /and ffect <br /> License#:I I � 'E�xpQ�tio�n�)D�at�e: 1 <br /> Date:�1_ D Contra for Vy u!r I <br /> 111 \ <br /> Signature: TIO . <br /> Printed name: — <br /> WORKERS' COMPENSATIOfl DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratlons: (CHECK ON E) <br /> I have and will malntain a certificate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Codo, for the performance 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 Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation Insurance <br /> carrier anitp0licy numbe. are: <br /> Cartier: cd Policy Number:— `!V <br /> I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in <br /> any manner so as to become subject to the worker•' compensation laws of California, and agree that if I <br /> should become subject to the workers'cornpensa'on provisions of�)on 3700 of the Labor Code, I shall <br /> forthwith oomp with those provisions_ <br /> Date: Signature: " �/j� •� <br /> Printed Name:I ; <br /> WARNING:FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL,AAD SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTII=B AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.), IN ADDITION TO I-HE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 7HORIZATION FOR OTHER THAN 13-57 SIGNING PERMIT APPLICATION <br /> of nature ofc-5 lip ad authoriasd re�p/r�rslentativra), <br /> harpbyauthodze(print nama) L IJ LSA_, <br /> Ltosi.((1,n thio San Joaquin County Woll Permit Appllcatlnn on my huha,Fr I wed. land alis authorization is valid for <br /> 1)yearandIs limited to thb work plan dated on the front page of this appllration. <br /> 7.!M1 <br />