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MId <br /> San Joaiqutn county Environmental H"10%9Mpartihent Uriit rV well PBrntiit AppllratlanISupplement <br /> AOSADDRESS: X36 Q �' •�f� PERMIT $th#: <br /> LICENSED CONTRACTORS DECLARATION 12121 <br /> I hereby affirm thOt I am licensed ander the provisions of Chapter 9(commencing with Section TODD)of Division <br /> 3 of"Business and Professions Code and my license is in full force and effect. <br /> Ucense #-. Expiration Date: I <br /> Date; 3-19-M Contractor. � S %4 ­b1zILu <br /> 5I0n4ture: �L Yftle .. <br /> Pd"W name: t. <br /> WORKERS'COMPENSAMN DECLARATION <br /> I hereby sfnrm larder penalty of perjury one of the following declarations: (CHECK ONE) <br /> thr <br /> t ySSection e and 3700 of the Labor Code,for Vie pertftoornianoe of the work for w1 ich this permit is issued.provided <br /> til have and voil maintain workers'compensation Insurence,as required by sewan 3T00 of the Labor Code, <br /> for the performance cr the work for which this permit is issued. My workers'cOMPOnsatlo"insuranca <br /> carrier and policy numbers are: ;3 <br /> Carrier. _Policy idurrit"n.b2 9 nta�^O <br /> 40 <br /> I certify that in the pesrformonoe:of the vmfk for which this permit is issued,I ahall not employ any peraan in <br /> any mlannerso as to become subject to the workers•compe3nattdon laws of Califorrita,and agree that if I <br /> should becohie subject to rhe workers'OMpereastion ptovisions of Section 37flo ar the Labor Code,l shall <br /> forthvWth Comply with thoas provisions. <br /> Expiration Date'?Signature: <br /> Printed halms: <br /> WARNiNG:FAILURE TO SI:CUM WORKERS"CO1aI P MISATION CoVERAGi:IQ UNLAWFUL,ITHOAMId SFIALL SUBJECT <br /> AN&PLOVER TO CRIMINAL pENALTWS AMC)CIVIL FINES UP TO ONE HVNDREQ YHGtJSA�Io DOLLARS <br /> IN DrrTION 3708 xM TO THE OF T COST <br /> GQDE. <br /> TOF (W.INTEREST,ATTORNEY'S FIM6,AND DAMAUES AS <br /> (PROYipEd FOR <br /> AUTHORIZATION FOR OCHER THAN C-57 Zia NINGi PERMIT APPLICATION <br /> �C3.V �R%tom- -6711csmaed mm orhmd repmentafiv*V, <br /> hereby aultaoHxs tprint namo t.aXL <br /> to sign tyle San.ioapuin Caunty Well permit AApilimson on my tlmhalf. i unfiaretsmd this:uttresnc�aCam la valid for <br /> one(1)year and is 11mi0ed to the work Plan daW#on the treat t38c of this aPPtica"n' <br /> IL-24-021 lAl <br /> eHD 19-A?AD: <br /> MV04 <br /> £d Wd6C:i0 4OW 61 'apW £886,Me sib 'ON aMOHd s isfi t pus v"az pur%040 <br /> f <br />