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San Joaquin Cotta Environmental He�$ervlcar,Unit IV Well Permit Application Supplement <br /> JOB ALIDRESS:/ Z45 F Cw!! ✓ %WRMIT SR#: D21O T <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commoncing with Section 7000)of Divlrion <br /> 3 of the Business and Professions Code and my license is In full force and effect. <br /> License d: SSS 57 7 Expiration Date: <br /> a/ ,',,//L•rS i /��FZ.+�'�'{ i�d c.c�nfL LJJL,� <br /> Date., 6`�'� 2 V Contractor: <br /> Signature: u . f�'" Tltl�! - ,iu^�•►L_.. �F��"e c'ti <br /> Printed name:�r C/�'.4+'�e di<-tfU7�f'T7 <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of psrjury one of the toilowing declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers'componsatlon, as provided for by <br /> Section 3700 of the Labor Code, for the perfnnnanrn of the work for which this permit is isuuwd. <br /> ave and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the pertormance of the work for which this panriit is iaeuud. My workers'compensation insurance <br /> corner and policy numbers are: <br /> S(,Z 60 0 <br /> Caller: �/ /xA✓t�e chi _ --.. . policy Number: ✓Y�4�f/�$ <br /> _I Certify that in the performance of the work for which this pormit is issued, I shall not amplov any Person in <br /> any manner so as to become subject to the workers'compertsatlon laws of California, and agree that it I <br /> should become subjer:t to the workers'compansatlon provisions of Section 3700 at mire Labor Gale,I shall <br /> forthwith comply with those provisions. <br /> Date: 60-OZ-0I Signature <br /> Printed Name: . <br /> GE 13 <br /> WFUL,AND SHALL <br /> AN EMPLOYER TO CRIMINAL.PENALTIC8 AND CML FINES uP'l0 NECURE WORKERS'comPrNSATION e HUNDRE LTHOUSAND DOLtARSuBJECT <br /> N A 3 IONTO 14E COS TOF HC lN CO <br /> CO ATION.INTEREST,ATTORNEY'S FFF.S,AND DAMAGES As <br /> PROVIDEDLr./-„-/ A. �GR..ErG'L�17'T— (c.67 licensed authorized representative),hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf. I undomtand thte auth,n"ison is valld for <br /> one(1)year and is limited to the work pain dated on the front pane of this application. <br /> 5Tt7-ggIMI <br />