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NOW, ' `1 <br /> $ACtJoaquin County ErlYlr treelltal Health ServICSS,Unit IV Well Permit Application Supple rne:ilt <br /> JC[3 ADDRESS.- �v ,to _ PERMIT SR#: DD2 3jr <br /> LICENSED CONTRACTORS DF-CLARATION (,�CDj <br /> it <br /> hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 9 of the gusinr3h�and Professions Code and my licanhrr is In fun force and aife:ct. <br /> ' License#: �` �131 expiration Date: o/_ 3/-4 3 _ <br /> ;1 Date: Z)3 28-6J Contractor._ d;VWr 414Z,-+.r-f�n-.e"-4 AJI <br /> fk SinatUe! - 71�Je• .•.' —mss a...t.tc_• ,�1 <br /> r. rr <br /> Piintel;f'nama,,- r c.�-frfirW bi ts�4-t'�1 _ <br /> WORKERS COMPENSATION VECLARATIW4 <br /> ; ;. 9; I hereby affirm under oianatty of perjury one of the toilowin0 declarations: (CHF.:CK ALL THAT APPLY) <br /> L:j <br /> I have and will maintain a c eP tlflcata of consent to self-insure for workers'aampensation,as provided for by <br /> 4• Section 3700 of the Labor Cotte,for the performanon of the work for which this permit is ititai ld. <br /> ✓ i have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> ru for the performance of the work for which this pen-nit is issued. My workers'cornponsation insuruance: <br /> =irrier and 21:T17- <br /> mare: <br /> , l <br /> _ Carrier: /,i S Policy Number: -z 2—kJ iS✓(- P 27`� <br /> k. I aertif that in the performance of the work for which this,permit is tyyuesd, I shall not employ an <br /> .74 i ., Y p P p Y Y person in <br /> any manner ao as to become subject to the wcurkers'compensation laws of California. and agree that if I <br /> t I should become subject to the workers'compensation provisions of Section 3700 of me Labor Code, I shall <br /> yyr' < forthwith comply with those provisions. -- - <br /> •' Date: Slonatur <br /> Printetd Nama---�6 44f 47-0 11 <br /> WARNING:FAILURE TO SECUR[WORKERS'COMPENSATION COVERAGE ISUNLAWFUL. ANI)SHALL St1FZ,lECT <br /> AN EMPLOYER TO CRIMINAL PENALTII=S AND CNIL FINES Uta TO ONE HUNDRE=D THOUSAND DOLLARS . <br /> _ ($100,000.),IN ADDrrlON TO THE COSH'OF COMPENSATION,INTERFST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LA13OR CODE. <br /> i F crFO p p - {C•57 iiconsod authotlwd representative),hereby <br /> ?f <br /> . a <br /> '�'.�.:. '' mutltorize_. C�f'lr-GS• �C.C.E]Z-^- Dle'r 141 <br /> 90��NG�'''d ��a L-�/►1✓'/lZJw3 /ij4'�. <br /> to sign this San Joaquin County Well Permit Application oi1 my hohalf. I unde fuland this aeuthorization Is valid for <br /> �i'P• <br /> e ." one(1)year and is limited to the work plan dated on the front paou of lhiea application_ <br />