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r <br /> 77 <br /> r <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplepurttt <br /> JOB ADDRESS: PERMIT SRS. <br /> UCENSED CONTRACTORS CDS <br /> I hereby aff n, that i am licensed under the provislens of Chapter 9 (commencing with Section 7t]WO)of Division <br /> 3 of the 8usin es_s and Professions Cade and my titans*Is in lilt farce and effect. <br /> La rose U! "J ��-7 Expir.Won Date: i©t f 8 2' <br /> Date: : Calntt'actor. Y-�' LO <br /> Signaturro: % T'd!e <br /> 041 e"- <br /> Printed name: `U)0 4 a e°rl <br /> WORKERS'COMPENSATIM DECLARATION <br /> 1 hereby affirm under penalty of per jury one of the fallovi tg declarations:.(CHECK ALL THAT APPLY) <br /> I have and will maintain a ceitfffcate of consent to for workem'campermallon,as provided for by <br /> Section 3740 of the Labor CoCe,for the performance of VIe work for whidt this permit is issued. " <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the labor Code, <br /> for tete performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier andel policy numbers are: <br /> Carrier._ i 1/4 ,r�, !R 'K -c policy Number. 0C �.5, <br /> I certify that in the perforn-once of the work for which this permit is issued, l shall not employ any per3cn fn <br /> any manner so as to became subject to the WWkM'carnpens*tion tam of Cafilbrnfa,and Mae that fi I <br /> should became subject to the waiters'compensation provisions of Section 3700 of the labor Cade,I shalt <br /> farft*rft comply with those provisions. <br /> Dab: Signature: <br /> MAW Nance: <br /> WAR WNG, FAtLfjRE TO SEC AW WORKIERS'COMPENSATION CCVFJqAGE 13 LIK AWFUL,AND SHALL 3VaJECr <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CML FINES tlP TO oNE HUNDRED THOUSAND t)OLLARS <br /> 100,W0.),IN ADINTION TO THE COSTOF WUrEMATiON,INTEREST,AtMRAIEY'S FEE9.AND DAIAAM AS <br /> _PRCV®ED FOR 1N SECTION TAB OF THE LABOR CODE <br /> 4 (C 57 ticensed authart and mpresentativeL hereby <br /> aurthariz. n t ✓Yt Li <br /> to sign Mir San Joaquin Cour Well Parmit Appittation an my behalf. 1 understand this atiftwbLerlon is valld for <br /> , <br /> one(1)year and Is Iltrtlted to On work plan dated an the front page of this appltcaffan. ' <br /> VIT-2=01 Ail <br /> s <br />