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artcnant Unit ry VNo11 Perrrrit APRic8tlOn 5upplemer+t <br /> � gAtn�Fieaith Dep <br /> SW Joaq ,co .y[Srlvnro;rm 0201 <br /> JOB ADDRIcS <br /> P��tMIT <br /> LICENSED CONTRACTOR' DEM ARATION LCD <br /> under the pm mons of Chapter 9(commencing with se0on 7000)of Division <br /> 1 hely sffrrm that i am Ilrens�d license is in fait farce and offer-L <br /> 3 of the 8uskvm and proWslons code and try <br /> 1=xpirstien Date: 1 all <br /> Contractor. r— LL� <br /> ts• <br /> oa <br /> Tide: <br /> S'rgria� <br /> prisrtiad nom: <br /> WORKSKS, CC)PAPENSATION DECLARATION <br /> I hereby aitw under penaltY of WuTY one of the following declarations: (CHECK ONE) <br /> for <br /> erfto Dance of the work for which this permit is issued, <br /> I have and wd meinteln a�riiflcate of oorrdent to <br /> s®li ineure <br /> for workers' compensation,3 i Provided <br /> by Section 3700 of the Labor Cede,for the p Section 3700 of the Labor code, <br /> have and will maintain workers' comp@nsation Insurance,as required by <br /> for#*perforrnanoe of the work for which this permit is issued. My workers' compensation ihsurarx e <br /> carrier and policy numbers arc: r 5 3`7 'e� CQ <br /> policy Number:�1 ? <br /> Carries: an person in <br /> rmance of tr►e work for which thlO permit is Issued,I shall not employ y pe <br /> I certify that in the perlb to the workers' Compensation laws of calftnla,and agree that if I <br /> Wy manner so as to becoma subjectrovislons of Sermon 3700 of the(„sbor Code,I shall <br /> should become eubject to the workers compensation P <br /> forthwith+bampiy with those provisions. <br /> slgnature <br /> Daw, <br /> Prirdw Name: <br /> FAILURE 70 SBGIlItE WORKM8,�pgN 1TION COVERADS IS UNLAWFUL,AND SHALL SUB+lSC7 <br /> AN�1-oygik TOiAtiiAL.PBWAL CML 1rIN&s I!P'� 7 ONE HUNORM T1`lOUSAN0 DOLLARS <br /> ATTORNL'Y's F' AND DAMAGES A6 <br /> IN ADVITION To TXE COS'OF CONiPI=lISA`IiON,�' <br /> (per �G Fop IN 8>!moll 370s of TNI-LABOR cODF- <br /> HORIZATION FOR 07HER THAN C-57 SIGNING PI-RIVIIT APPLICATION <br /> (signature ofC-v ftensed euthorlsed representslive I, <br /> i <br /> hereby 2s( is rr8me <br /> to sign this San Joaquin County Well Permit App <br /> frcatian or my behalf. 1 unQerstend this authorization is valid for <br /> one(1)Year and Is limited to the work plan dated an the front Page of this applic"on. <br /> IA/791 <br /> JIB 0�1 �f1.Lb211� fi8Q99L96E5 8599 ce9z/sTJ9e <br />