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San Joaquin County Environmental Health Services,Unit IV Well PQrmit Application Supplement <br /> JOB ADDRESS: IM SowTH CgArrE�c err PERMIT SRO: <br /> Fracas rail, CR <br /> LICENSED CONTRACTORS DECLARATION ( $) <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. <br /> License#: �S^ Expiration Date��1���0 6 <br /> Date: G Contractor.- oer f ' U//ill/�� T r.�� <br /> Signature: Title:— G [��a7i�cg <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of peryury one of the following declerations: (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 he, <br /> * <br /> and will maintain workers'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 numbers are: <br /> r t <br /> Carrier. Policy Number:e 72/9yG/ 1310 2/ <br /> I certify that in the performance of 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'compensallon laws of California,and agree that K 1 <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Cafe,I shall <br /> forthwith comply with those provisions. _ <br /> Dater. r G' Signature: e44 .� �_ <br /> Printed Name: er C//I l" <br /> WARNING:FAILURE TQ SECURE WORKERS,COMPENSATION COVERAGE 18 UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES IIP TO ONE HUNDRED THOUSAND DOLLARS <br /> (1100,000.},IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTCRNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> r <br /> 1. C&1CYZ2LZ (signature ofC-37 licensed authorized representative), <br /> twobyauthorize(printname) .Sher✓JP_ 1CA11G rr <br /> to sign this San Joaquin County Well Permit Applicatlon on my behalf. I undaratand this authorization Is valid for <br /> one(1)year and Is limited to the worts plan dalad'on the front page of this application. <br /> S-17-20001 MI <br /> 06 19bd 2100_U HljIJ EEOF.R90606 1E.ET 6eOL/Pe/7-1 <br /> Z8/Z0 3Jkld 210035 OE1701989% 80:9T POOL/T0/Ce <br /> a -d 0026 13rd3SH1 dH Wd61 :1b, b002 10 MUW <br />