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- - <br /> 0O2) <br /> San .luaquin County Environmental Health Ueparrtment Unit IV Wall Pntmlt . <br /> JOB ADDRESS ; 120, s �fl�t up <br /> tt , j! - PERMIT 513#� �i <br /> LICENSED CONTRACTORS DECLARATION CD <br /> I hereby affirm that i am licenund under the provisions of Chapter 9 (Commencing with 3er-tirni /0911) of Oivfnion <br /> a of the Husineas and P14tlx33ions Code and my tinenso is in full force ivid olfuct- <br /> I Imulse #: SS,.y971 Expiration flats: __61- 31 " 61 <br /> nate.: . ...(f +" �-�._8 `u�-' ConUctor __ „ yrb-r' !7'f2Mn1� ' QJIt-jLGl .-rd r'�a /azj' <br /> 8lgnalurnt OL <br /> Pti rti3 r)attre. ! c !-FH7t.o62,�e <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury ono of die following dealaratlans: (CHECK ALL. THAI' APPLY) <br /> _ I have and will maintain a cafflhuate of rnnsent to self-insure for wnrKtxa' rnmpenyatjnn, as provided for by <br /> /Section 3700 of the Labor Code, for the performance of the work for which this permit Is itsuud. <br /> ,G I hive and will maintain workerV' rompensation insurance, as required by Section 3790 of the 1 ahor Cotte, <br /> for the pus foananre of Olu work for whirls this permit is issued. My workers' cofriputlataUon insurance <br /> c:,ri irrr and poli y numhPrs are: <br /> Policy Number: Z GJ 191�a /7 z� 'II <br /> I rofifty that in the purfor mance of the work for which this permit is issued, I shall not employ any poison in <br /> any manner so ac to become :subject to the workers' compensation Inws of Cttllbrnia, wid agrou that if I <br /> should beconur r:uhiuct to the workers' compensation provisions of Section 37610 gt_the+--Rbar Cudh, I shall <br /> luithwith ramiply with those proviuions � <br /> r/ <br /> Data: _ . ._. Q nd.. a to G2-- „ Slgnatur ��Z/ <br /> Printed Na _~~,� <br /> WARNING: FAILURE TO SECURE WORKERS' CoMrENSAtION COVERAGE I5 UNI AWFUL, AND SHAT I . SUBA =CT <br /> AN rMPLOYER 61 O CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND OQLLARS <br /> (51001000 .), IN ADOITION TO THE COS I OF COMPFNS4K7ION, IN I FREST, ATTQRNLj#S FEES, AND DAMAGES A3 <br /> PROVIDED FOR IN SEC'I )ON 3106 OF THE LABORlCCOOF- <br /> 1, ~` - / Gr-/ .1Y47 X, <br /> Ile <br /> (/� 71S7LLr [rli7 ! <br /> ,_.. _ . . - .. -._ .._—.—.— rte. -. .,._(yiNnAttlre otC -5'/ licenyxd aWhorjind repr95xntabvxj, <br /> horeb7y autriorize (print nwtCl � /1 tJG y6'7'bd� ... dF N/. era . G� ✓//1.✓.� r j •r'Z, <br /> to sign this San Joaquar County Well Permit ApplicAtion on my Whxlf. I understand thin xuthorUatlon m wUld for <br /> one (1 ) yoar and In limited tu the work plan datad on Ofd front page of this appllcabom <br /> 1 .26-021 MI <br />