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rt � <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 6V Z I Q tL- AVS PERMIT SR#: DD�Va <br /> I- pot I c 175Z' S <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <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 Professions Code and my license is in full force and effect. q <br /> License#6: 10 (� O 2 2 / Expiration Date: V ef� ��/� 2 0 O <br /> Date: 07 hh � C) Z—contractor: 1 —tvc� ce.n D/) M 4 � �. <br /> Signature: / L6 _�+J�— --Title: ho E�� o /o <br /> t <br /> Printed name: Nin m A rl�T ✓ Q 1110 <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 /> I have and will maintain workers' compensation insurance, as required-by Section 3700 of the Labor Code, <br /> T for the performance of the work for which this permit is issued. My workers' compensation in urance <br /> carrier and policy nuers are: �C}. <br /> STR E <br /> Carrier: -A5\1 f f INQ FJNv Policy Number: -7 7 L 2!) <br /> l?c 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 /> forthwithh comply with those provisions. <br /> Date: / ' ' OZ Signature: <br /> Printed Name: J r ) r14 <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1 (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 1-25-021 MI <br />