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10-31-1995 10:SGPM FROM P. 3 <br /> "bu UN:G4 rAA 1 Sia U4JU .yt:t:ux-.Se1(:xeLMl:�!'U �. io u112 <br /> San Joaquin CourRy EWAranrneat3A eeMh teff, Unit IV Well Permit Application Supplement <br /> [JOB ADDRESS: 1b1 s4 5- tiff tacro4FPERMIT SR*: QQJ/�� <br /> r�tsra.,P,riff <br /> LICENSED CONTRACTORS DECLARATION (!&PJ <br /> 1 hereby affirm that i am licensed under the provisions of Chapter 9(commencing with Section 700D)of Division <br /> 3 of the Business and Professions Code and my license is in full.force and <br /> �effect, <br /> License N: tel.°:1� J Expiration Date:�l `o <br /> Date =Z t,L� /Contractor. h 1 (3 n �� Q <br /> Sl9nature 1 r _, Title. nt ��Q— <br /> Printed namerQ. <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury One of the following declarations: (CHECK ALL THAT APPLY) <br /> I nave and Will maintain a certificate of consent to self-insure for workers'compensa%n,as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is=uW. <br /> ✓I have and will maintain workers'compensation insurance,as required by.Section 3700 of the Labor Code, <br /> for vie performance of the work for which this permit is issued. My workers compensation insurance <br /> carrier and pal icy qumbers <br /> 7 <br /> Carrier: �� ! Policy Number: <br /> I Cenity that in the partonrlartce Y)4 the work for which this permit is issued, 1 shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that 4 1 <br /> should become subject to the workers'compensation provisions of Section 3700 Of the Labor Cafe. I shall <br /> forthwith comply w8hltrios&provisions- <br /> Date:_.�f aL1/`Q� Signature: <br /> Printed Name:_V <br /> WARNING:FAILURE TO SECURE WORKER$'COMPENSATION COVERAGE IS UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINEST UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (3100.000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S F'FES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 370E OF THE LABOR CODE. ' <br /> 1, J (`J y-y$G/-} _,_(slgnature OIC-57 ficenaad authorized reprecentaffve), <br /> hereby suMorize(prtrrc <br /> to 31911 this San Josquln County Well Parmlt Appllwffon on my Dertatf. I understand this authorization is valid for <br /> one(I)year and 13 tlmhed tD the work plan dated on the front page of this aDDllentlon_ <br /> 5.17.3,000!MI <br />