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San Joaquin county Environmental Health Department Unit tV well Permit Application Supplament <br /> JOBADDRESSJV A Q24&, k +T fxk6i Papmr spar: :615gD <br /> LICENSED CONTRACTORS DECLARATION I( CCI <br /> I hereby affirm that I am licensed under the provmlons of Chapter 9 (commencing with Section 7000) of DivislOn <br /> 3 of the Business and Profeaoions Cods and my litems is in full force and effect. <br /> License # ;71 00 �7 g Expiratl0n Date: r7 Il -- <br /> Date: 'j ,7"16 'z Contractor k r crr Q L-rJ <br /> Signature: <br /> Printed name: h) C i >J� t e. 4421 AJ J22f<,Q <br /> WORKERW COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _ 1 have and will maintain a eertftats of corwRtnt to aaN-insure for workers' cnmpenset1w, p6 provideo Tar <br /> by Section 3700 of the Labor Code, 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 ofthe work fw which this permit is issued, hlyworkers' Compensation insurance <br /> carrier and policy numbers are: O 'y <br /> Carrier: '"" -c-lis"-r'�' Policy Number: f.J �[� .� �-� �C / <br /> f codify that in the performance of the work for which this permit Is Issued, I shall not employ any person in <br /> any manner eo as to become subject to the workers' compansation laws of California, end agree that if I <br /> should bacome subject to the workers' compensation provisions of Seetion 3700 of" Labor Cod., I shall <br /> forthwith comply with those provisions. } <br /> Expiration bete: 6 D K. Slgnaturp �l c^ �`� `� � z — •� <br /> C <br /> Printed Name: Co !Jo tJ,4-ifr' t) <br /> WARNINOi FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIER AND CML PINES UP TO MIR HUNDRED THOUSAND DOLLARS <br /> 01001000t), IN ADMION TO THE COST OF COMPONSATION, INTEREST, ArrORNEY'8 FEE% AND DAWAGFS AS <br /> PROV_IDEp FOR IN SECTION 3766 OF THE LABOR CODE. <br /> 1AUTHORIZATION FOR OTHER THAN Ca57 SIGNING PERMIT APPLICATION <br /> is L rT—,c,/�( �-��,,,_�/ fatynature oM-57licensed auafortaad mph fibl: va), <br /> hereby authorize (prim name) !—� uS �11N�Ln 7, C <br /> to elan this San Joaquin County WON Permit Application on my behalf. I understand this a dhorkaaon Is valid for <br /> one (t) year and is limited to the worn plan Wlmd on the front page of thIa appllcauah. <br /> 5-29-02 f MI <br /> sun 2voa-on, <br /> 6/X71!)d <br /> EB /Z0 39t1d anon nN SnIuNiG <br />