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5-14-1995 2;20AH FROM P. 1 <br /> FILE COPY <br /> San Joaquin County Environmental Health Services,Unit IV well Permit Application Soppienwnt <br /> JOB ADDRESS. 1050 So,TM�b a AT+. St„ ktor PERMIT SR* <br /> LICENSED CONTRACTORS DECLARATION LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section Two)of Division <br /> 3 of the Business and Profusions Code and my!icense is In tuli force and effect. <br /> License#. c� �D S Expiration Cate: - '�'cw�7- <br /> w <br /> Date: ����) `�� Contractor: <br /> Signature: Title; _C?.y-,q ' r <br /> Printed name: J 114 ✓l( Sc,d-i _ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affim.under penalty of perjury one Of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will mairitain a certificate or consent to self-insure for workers'compensation, as provided for by <br /> Section 3700 of the Laoor Code,for the performance of:he worK for which this permit is issued. <br /> t/have and will mairlYdin v+cnters'canpersat(on insurance,as required by Section 3700 ofthe Laba Code, <br /> lerthe performance of the work for whic's this permit is issued. My workers'compensation insurance <br /> IIS carrier and Policy num`�bers are: <br /> { Carrier: 4;404 (/"I� FW 1 1i Policy Number: <br /> I certify that s the to become <br /> s of the work for whim Tis permit is issued, i shall not employ any person in <br /> any manner so as to become subject to Ne workers'compensation laws of California, and agree that ff I <br /> should Become subject to the workers'compensatior,provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> /77-- <br /> Date: - �' { Signature: <br /> Printed Name: <br /> i <br /> WARNING:FAILURE TO SEcUR£WORMRS'COMPENSATION COVERAGE 19 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER To CRIMINAL PENALTIES AND CIVIL FINES Up To ONE HUNDRED THOUSAND DOLLARS <br /> (2100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,A^ORNEY'S FEES.AND DAMAGES AS 1 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR COOS. <br /> i (C-57 licensed authorised npretrentative),hereby <br /> +I� authoi <br /> i to sign this San Josgvin County Well Petmit Application on my behalf t understand this authorization;a valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 5.1.7.X00 f MI <br /> ::n 'a<M f b nIC� nW CF9F�C1 n_cm 7o-or rens renter <br />