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van Joaquin County Environmental Hrmlth uepartment IJnie IV WcU Pdrtnrt, dwM <br /> D03l� <br /> JOB ADDRESS: /�j S ..�d` � PERMIT SR#'���/ <br /> LICENSED CONTRACTORS DECLARATION (QLDj <br /> I hereby affirm thdt I am licensad Wider h,e provisions of Chapter 9(Maimencing with aer:tirni 1000)of Civiaion <br /> :3 of the HuatnueS and Prufessions Code and my linense Is in full force lrrd slfout Expiration sista: 61- 31-61 <br /> hHtP.:. ...� i �.._U�� Ctllltraf;flll' G+S-r 1-142-MA lr�/t-lLL�,j6 C-6" <br /> Slgnakurne�_ C-r •....Y. e. ►�irle� ..��'id,�nZ fr9r��L'Y�- <br /> l WORKERS' COMPENSATION nECLARATfIQN <br /> :j <br /> I hereby atfirrn under penally,of perjury ono of the following deularatlons; (CHECK ALI.THAI'APPLY) <br /> I have and will maintain a rer1dit:ate of cnnseet to self-Insure forworkers'r.rrnpensatlon, at;provided for by <br /> Section 3700 et the I_ahnr Cudu, fop the per of thr.work tar whiLYt dile;pu±rmit is i+suad. <br /> Zhave and will rl1;ttintain workers'oompetwatinn insurance., as reyuilad by:iuiAon 3700 of the I nhor Code, "! <br /> for the per forniol1re of Ilia work for whir.ii this permit,is Issued. My workers'compurls:allon insurance <br /> uarl iur find poli•y nUmpprr,etre: / <br /> S .. ... Policy Number. W f9✓d/�z�N I <br /> ' I certify (fiat in Ihir purloin rice of the work for which this permit is issued, I shrill not employ any pa,soh in 9 <br /> any manner so as to becume aubjeet to the workers'compensation Jaws of Cnllforruu, wad agrou Ilial if I a <br /> should becornu r;ubjuut to the wnrkery conrpanSr'Y,hqn provisions of Section 3700 cy lila L-abaI,Ceder, I shall <br /> lurthwlth nmiply with those provisions <br /> Sig na <br /> Elatg. , ,QS' 0$•02_- Printed Narr`-- / fir �.�f• ...I�n��--CiHY?r .�_ Iffi <br /> WARNING:FAILURE To SECURE:WORKERS,COMPENSAIION COVERAGE tS UNI AWFUL,AND$HAI I.5Ue.It4r <br /> AN FMPLOYEH'I O CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNI)RFn THOUSAND [10111.ARS <br /> ($100,000.), IN ADDITION TO THE Cost OF COMPENSATION,IN I'iikEST,ATTORNLY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN Skf,•'I'ION 31OR OF THE LABOR CODE- <br /> .; <br /> 1,..—..� _.. ...._....- _.. ,.....�.("IrlrrAblrle etc-57 licenmxd authoriSnd ropro5rintatrvo), <br /> hereby authorize (print naau) fl u 4 6'7_"4,'•.1 4e- it/. ,5;;D, G�.•U✓ryt,r.�,- j.r'Z,. <br /> to slgn thus San Joaeuw County Well Permit Application on my behalf, I understand this suthorizat(un u valid for <br /> ono(t)year and Is limited or thb work plan dated on tho front paya of this application. <br /> 14"2 MI -' <br /> i <br /> 1 <br /> {i <br /> I <br /> j <br /> it <br />