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I <br /> IF FFF <br /> San Juaquin County Environmental Health Department Unit IV Well Punnet . D� 3!` <br /> JOB ADDRESS. IZOj S` C , ..� � PERMIT SIR &J2 w� ?i <br /> LICENSED CONTRACTORS DECLARATION CI7 <br /> I hereby atflrm that i am licangad Wider the provisions of Chapter 9 (Carnrmeneing with berfion 1000) of Division <br /> 3 of the Hn511ieao and PIIANBSInna Code and my Iirrmse is in full force and arhx:t. <br /> I lronrn #: SS,.`1r97, 1� Expiration f7ffie: � 61- 31 - 01 <br /> rete: . OP,- 0 $ x12 Contractor __ . . 5r= 94Zr" A +r1D1trC1. 1 , j6 L,6 iv <br /> 6lgnaturnl ,. y L r ..._ r! f�itfn: Kid rC �rr� �Yt <br /> —. , .. _. <br /> l WORKERS' COMPENSATION DECLARATION <br /> I hereby aB rro under penally of perjury One of lite following deolarahons; (CHECK ALL. THAT APPLY) <br /> _ I have and will marntam a rtiwtrfivala of cnnserd to selfmosure forworkern' rnmpensatinn, as provided for by <br /> Section 3700 of the Labor Cude, for the perFunmance of the work for which d"115 permit Is issued. <br /> / <br /> ,� I have and will maintain worker' rompensatinn insurance, as reyuhtod by Section 3700 of the I atior Cotie, <br /> for the par forintance of f is work Mr which this, permit is Issued. My workers' Componsabon insurance <br /> carr lar and poi y numbers Are: <br /> I/C/airier: !?7,rCd/L-�J INS ... .,:. Policy Number: GJ fy ✓6 /a a75/ I .. . . <br /> I Gf',fflfy ilialIn lfle 11HIIUrIYl2rC4 Of the work for WI1iCh (PIIS pP.rYtlll I3 i3sued, I shall not employ any parson in <br /> tiny manner so ac to becume subject to the workers' compensation TAWS of California, and agree that if I <br /> should beconul Im Ihjerl to the workers' Wrlipnn9ahon provisinns of Section Mn yt the9-Labor Cuda, I Shall <br /> IUIUIwith ranply with those provisions <br /> Date: Q 8' / w <br /> Signator .--- <br /> 11F+1144 IF 1. <br /> � l <br /> 1 <br /> Printud Nd(iwd �cLet++r+ P d! • 0 �4 Ci+rly > <br /> WARNING: FA0.URE TO SECURE WORKCRS• COMPENSAIION COVERAGE IS UNI AWFUL, AND St+AI I . SUBI <br /> AN rMPLOYEH 'I O CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNUREn THOUSANV 0011F.ARS <br /> ($100,0110 .), IN ADOITION TO THE COS 1 OF COMPFNSATION, IN I F.:REST, ATTORNLry#S FETES, AND DAMAGES AS <br /> PROVIDED FOR IN 9kG'l1ON 3rOg OF THE LABOR CODE. <br /> (r 4 i G rl eFIFF A 1A.,d1 ,Ve,4 ?Fo <br /> O,tt/e -57 ticunurxd autherixnd representatrval, <br /> hereby autnorize (print nar.(u), ^ pfl t1 yd'7'b6�-.) 4F ,/r,r/ �a�a , G�.L.P✓//LJ. 1 .^ n�Z,. <br /> to Sign this Sart Jeapum County Well Permit Application on my behalf 1 udderstand this autharlxatiwr cv Valid for <br /> 0110 (1 ) year and Is limited to the work plan dolled an tilt: front page of ibis application, <br /> 1 -it5�Z / MI <br />