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nut,-lb-U1 Pxl 2:43 FM X D. E. FAX N0, 916 852 9535 P. 2 <br /> Bath JJoaquin County Environmental Health Serwes,unit N Well PYrmit ApptiCi bion t3UPplemml <br /> dOB ADDRESS: OS �kl�� tnrJ4 PERMIT SR#: <br /> LICENSED? CONTRACTORS DECLARAMON (LCQ) <br /> I hereby affirm that I aril ii0amed under(he provisions of Cnaolar D(Commencing with Soction 70001 of Division <br /> 3 of the Business and Professions Code and my license is to full force and effect. <br /> ExpiratiionDate: t/73 <br /> Data:�""�� +� Contracfar: <br /> 8119rtalUre: TIIIa: r J <br /> Printed name: Ah/.41-01 �! JTn- ----- <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm under penelty,of pedwy ono of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and wki maintain a cerhifoole of Consent to sett-insure for workers'compansaticn.as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is Wsued. <br /> x-I have and affil maintain wakens'ownpansellon Insurance,as required by Section 3700 of Me Labor Code, <br /> for the performance of the work for which this pemdl is issued. My workers'compensation insurance <br /> carrier and policy rtumbars era: //���/ � �, / <br /> Cerrler..s --Policy Number;JST-0 U!.y.�_-0 l— <br /> I owtify that in the performance of the work for which this permit is tssaad,I shall not employ Sny person it- <br /> any <br /> nany mannar an as to bacon a subject to the workers'compensation laws of Califomta,and egree ttrot it I <br /> should become subject to the workers'o ompfnfe6on provisions of Section 3700 of the Labor Code, i shaft <br /> forthwith Comply with those provisiorm. <br /> i <br /> Date-, Signature. <br /> Printed Nam*: _ <br /> WARNINQ FAILURE TO SECURE WORKEW COMPENSATION COVERAGE IS UNLAWFUI,AND SHALL SUOJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL,FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED S OAF OF COMPENSATION, <br /> SAWN,INTLREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> RD FOR IN SECTION <br /> h/(aRr©© 'p1 �l I l J 7 Ic ST nice se/d authcrl:ed reotesenfatNe), fly <br /> auUro(tsa, .C7 e I .�.:., Zt? O f /fol a U-� � <br /> to sign this San Joaquin County Well Permit Application on my beball. I understand this AuthorbAlon Is valid for I one(1)year and b Nmited to the work pin dated on the front pays of fids sppliCAticn. <br /> 647-20"1Ml �........_. _._._— _.._....._..---.--- •---- <br /> t8%78 39Vd NOLAX16 Dnp 9TTT.L911ERZ VZ:SP, 199Z/91 ?9Q <br />