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LIP <br /> ------------ <br /> Sart'Joaquin County'nvironrnental Health Services, Unit IV Well Permit Applies#ion Supplement <br /> JOB AADRESS: r _ PERMIT SRS`• t��2 S���� <br /> LICENSED CONTRAC R5 DECL141 ATION- L�d_D_3 <br /> I hereby affirm that l am liuensed under the provisions of Chapter 9 (commencing with Section 7000)of Diviaton <br /> 3 of the Business and(professions Carle and my license is in full force and eftoct. <br /> License#: S`(�1`� Expiration Date: e 1- .1 <br /> Date: contractor: �✓ �� �7 ��.... •„,:7 _ _ ._ <br /> Signatura: Title_ <br /> Printer!name: ���� e•� � <br /> WOPKERS' COMPENSAT1014 DECLARATION � <br /> I hereby affirm under penalty of perjury one of tine fallowing declaration$: (CHI=CK ALL l'1$AT APPLY) <br /> I have and will maintain a certificate of Gnn%ent to self insure far wor'kiirs'compensations,as provided for by <br /> Section 3700 of the Labor Cuda, for the pe ftrmanca of the work for which thls permit is issued. , <br /> ✓ I have and will maintain workers'compensation insurance,0*required t,y Sar:tion 3700 of they Labor Code, ' <br /> fcx,trio performance of the work for which this permit is issued. My workats' t;ampen$000n insur3riCe <br /> ” cafrier andpolicynumbers are: <br /> Carrier. / ✓�m.S .-policy Number• <br /> 1 cartify that In the pe.rformance.of the work for which thin permit is issue+td, l small not employ any person in <br /> any manner stn as to become subject to the warkers'compensation laws of California, and agree that it l ' <br /> should become subject to the workers'compensation provislons of 91 �On 3700_pt#16_L.0b0r Code, I shat <br /> forthwith comply with those provisions. <br /> Clete: b/ Ib-� I Signature. <br /> Printed N:xrna� <br /> WARNING:VAIIUlRE TO SECURE WORKERS'COMPENSAMN COVERAGE IS iUNLAWFUL,AND SHALL 5UR JIE,CT. � <br /> AN EMPLOYER YO CRIMINAL PENALTIES AND CIVIL.RNES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADUlTtON TO 114E COST OF COMPENSA-I ION.INTIrtEST,ATTORNEY'S FEES,AND DAMAGES A5 <br /> PROVIDED FOR IN sEC'CC ION 3706 OF THE LABOR CODE. <br /> ZZ, A_�b"u,6" C.•57 licensed authorized r'epresentZ*—).haraby <br /> authori�w iLL • [.G � d/i4�JGt-�Q � <br /> to sign this San Joaquin County Well Peri lit Application an my behalf. I understand this authorization 1%valid.for <br /> Is limited to the work Ian dated an the front Page of oris application. <br /> ane{i}year and !R - ` <br />