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Jul- IL ZOO 'Wupm A' •6ced GeahvironmentilE � No. }40y P. 3/3 <br /> 61514 ^� , � l I <br /> ka^"1'i" <br /> San Joaquin County Errviironmental llaalfb lhwnamnene Ilnnt rV Well Permit Application supp(emetd <br /> JOB ADDRESS:_C �1t�f �KWwd PERMIT SR#: IGV Z�,b <br /> Afe�ta FOSwavKlizl Avt ' <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 700)of Division <br /> 3 of the Business and professions Code and my license is in full force and effect <br /> License#� l D l lU '-i'�i� Expiration Date:_ !c))-j l JQ W <br /> Date: ! 0�J' Contractor <br /> Signature: lam' _ C9f�Fir�al t'Y� <br /> —�---_ 4 _ <br /> Printed name: <br /> WO S' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-Insure forworkers'compensation,as provided for <br /> by Section 3700 of the Labor Cade,for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for wtkh this permit is issued. My vmrkers compensation insurance <br /> carrier and policy numbers are: <br /> -{� p <br /> CarrierS�k,� policyNumber. 11 � y0 � <br /> I cer ify that in the performance of the work forwhich this permit is issued,I shall not employ any person in <br /> any manner so as to become sdbject to the workers'compensamon laws of Cafdomia,and agree that if <br /> shot become subject to the workers'compensation provisions of Section 3700 of the Labor Code,1 shall <br /> forthwith comply with those provisions. /p <br /> Expiration Date: f '�r /yi9nature: <br /> Printed Name_ j=—, <br /> WARNING:FAR-UPIE TD SECURE WORKERS' -COVCRAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> 0100,060.1,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR <br /> OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> "�.f1 , <br /> 1, "0-2"-1 <br /> LAII (signi ofCST 111maud authorized repn:=ntavve), <br /> bereby authorise(pint name �,.R, <br /> it <br /> to sign this San Joaquin County ppli,,Uon on my behalf. 1 understand Oils authorization Is and for <br /> one(il year and m Ikmted to the work pian dated on Me frord page of thK appleatlan. <br /> 9-29-02 r MI <br /> EHD 29-0b001 <br /> 6/1Ne1 <br />