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10-31-199S 10-SSPM FROM P� 2 <br /> ..v.v v. ••u. .0111 rnn A 01V U4JV Dt:WX-SH61(iftIL:V 1V 40 UO.) <br /> /6 `fes c�41� <br /> r SanJoagnd Iron �II me, h SgMces, Unit IV Weft Permit Application Supplement <br /> JOB ADDRESS- V a Lf 1L� =�a�[i+.vr�-.GcGr7c�j^.� PERMIT SR#: Z[ d LS <br /> l.atw�oP,v <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I horaby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is In full force and effect. <br /> License a:_62e8966 S Ettpirmion Date: <br /> 1riso4 Cnwled1)n <br /> Date. __ . _:�Sl�i� contruxor: <br /> -�- //� <br /> Slgmature:_ i Title: •"W,L. <br /> Printed name= _ 211 Vl t({<'Gl l <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers compensation, as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> - V i stave and will maintainworkers'compensation insurance, as required by Section 3700 of the Labor Code. <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance ! <br /> carrier and policy <br /> PDX <br /> are: iI <br /> Carrier: �7a 7 p I OX jo Policy Number: <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 workers compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall <br /> forthwithComplyComply With those provisions. <br /> Date 7 a7 '�a' Signature: ,��� <br /> Printed Name: .7111 V!L' CG,fc i <br /> I <br /> WARNING:FAILURE 70 SECURE WORKERS'COMPENSATION COVERAGE 1$UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RHES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S101i ).IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR M SECTION 3706 OF THE LABOR CODE. <br /> 4�.C�^—.t"'r(1/ , ' :SGI'7r _.----,---(signature ot"7 licensed auUwilzed raprasentml�el, <br /> horeb authortze rant nems Mtaen <br /> i <br /> to sign this San Joaquin County Well Permlt Application on my behalf. I understand this authortzauon is valid for f <br /> one(1)year and is limited to the woek plan distad on the front page of this applleaaon. <br /> 5.17-20001 Mi <br />