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I <br /> L <br /> I <br /> i <br /> San Joaquln County Environmental Health Depwtnwrrt Unit PV Well ParmltApplkation Supplement � <br /> -JOB ADDRESS: E. PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION L( CD1 <br /> I hereby affirm that I am licensed wxier the provisions of Chapter 9(oommencing vAth Section 7000)of pulsion <br /> 3 of the Business and Protbosions Cade and my license is in toil force and effect <br /> License t Explratlon Dete: <br /> Date: Ln t�01 Contr'acbr. ! <br /> SwAdure: �f 9n1,�1 �' J �,��� Title: �✓l�A[.�1�►`' ` <br /> Printed name: ' f- <br /> i <br /> ERS'COMPENSATION DECLARATION i <br /> i <br /> I hereby afRrm urxter penalty of perjury we of the folio"declarations: (CHECK ONE) <br /> I have and wIi maintain a csxtlfIcale of consent to*off-Insure for workers'eompermlillon,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this per rit is issued. i <br /> I haft and will maint8in workers'cornpaustion Insurance,as required by Section 370D of the Labor Code, <br /> fir the numbers <br /> of work for which this permit is issued. My wosic W compensation insurance <br /> carrier and sa �, <br /> Carrier:,,�, +U� 2- _Pun Posey Number. <br /> I certify that in the per fbimanoe of the work for which this permft is issued, I shat not employ any person in <br /> any manner so as to become subject to the workers'compensetton Iays of CalMomia,and agree that N 1 , <br /> %'*ad became subject to the workert compensation provWons cf Secticn 3700 of tie Labor Code, 1 shell <br /> tbrltwrth comply with those provisions. (� J <br /> Expiration Date:J—U Slpnature: lS[Y 2PJMn.) L6� i i14-4-j— <br /> Prinw New __�Q <br /> WARNING:FAILURE TO 5ECWM WORMERS'COMPENSATION C GE IS UNLAWFUL,Alm fSHAI.I?,SUBJECT <br /> AN M .OM TO CII■AR1AL PENALTOW AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (HOMO Ra,IN ADDRION TO THE COST OF OOMPH ATION,QST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVWW POR N SECMN 3706 OF TM LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, signttun o11367 licerwed authortzsd rapresenfatlwh <br /> hereby suthortw rant nom <br /> to sign this Ban Joagaln County Wall Permit Application on my behalf. 1 un this authorhation le valid for <br /> one(11)year and is nmilad to the wo►1r pian dated on the front pada of this application. <br /> 8-2!0211U <br /> END 29 001 <br /> 6MC4 <br />