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I <br /> r- <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOS ADDRESS: i2,) 1 5• fFtITEQ a�r ?ldfLrnn/ . Q PERMIT SRS, DDZ. O <br /> LICENSED CONTRACTORS DECLARATIONL( CMS) <br /> I hereby affirm that I am licensed under the provisions of Chapter a (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 #: Expire0on Date: /Z 51 /<:)I — <br /> Date: 'Contractor C7YEr.}c.,. <br /> Signature: T7tfe: _prge,rc f aQ / hIr yTr <br /> Printed name: iy75}a�yr ey P✓Vr tCy _ _ <br /> WORKERS" COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to se[Nnsure 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 /> ZI have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Cade, <br /> for the performance of the work for which this permit Is Issued. My workers' compensation Insurance <br /> carder and policy numbers are: <br /> Carrier: /n4G)C Q' PQYk.Aey, PollcyNumber, W C.Z. 1ls;OrW. (oO <br /> 1 _cert4`y that In the perforrtafu:e of the work for which this permit is Issued, I s all not employ any person In <br /> any manner so as to become subject to the workers• compensation laws of California, and agree that if 1 <br /> should become subject W the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provlsione. <br /> Date: 7 / Zo /<01signature: <br /> Printed Name: C inrr,5tybcrI PVv1N tkY <br /> WARNINWm FAILURE TO SECURE WORKERS• COMPENSATION COVERAGE 18 UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER To CRIMINAL PENALTIES AND CIVIL FINS11 UP TO oNE HUNDRED THOUSAND DOLLARS <br /> (510000.), IN ADDITION TO THE COST OF COMPENSATIt7N, INTEREST, ATTORNEtf'S FEES, AND DAMAGES AS <br /> PROVIDED FOR <br /> IN SECTION 3106 OF THE LABOR CODE <br /> L 01� ��^ (Cyy licensed authorized representative), hereby <br /> avthcrla. � L <br /> L <br /> to elan Ihta San Joaquin County Wall Permit Application on my behalf. ( understand MIS authorization Is valid for <br /> one (1) year and Is limited 10 the work pian dated on the from page of this application. <br /> 517-20001 MI <br />