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WOODIJARD DRILL?t;1G CC PAGE 03 <br /> 09/19i 2eei 69:4',3 7t9 r _ 3 D10DESTO ATC p4G;' 03 <br /> NAr lhi 2FJfl1` 11_48 _ 2©9-5;9-=x_:.5 <br /> San .tolqumont <br /> in County Environmental Neatth Servic♦s, unit IV Weil Permit Ap¢licatiort Su'opte <br /> ! DD MIdcc EMT SR#: (JJ,Z� <br /> JOB ADDRESS: 3j'3 <br /> I <br /> 1 <br /> LICENSED CONTRACTORS DECLARATION ) <br /> 1 Hereby affirm tenet t am licensed under th8 provisions-of Chapter 9 (comrnencir<9 with Section 704fl)of Division <br /> j 3 of the business and Professl,ns Coda and my <br /> license is in full force and effect. <br /> rt Expiration data: 7' �i"���' <br /> jLicense#: <br /> �_'p` p'< Contractor: �� � lA <br /> Data: �aVt%Y�.iS P7ANi4f..4FX- <br /> Titie:Qj! <br /> 81griature: Ir <br /> Printed name: <br /> WORKERS, COMPENSATION DECLARATION <br /> I hereby affirm under Penalty of Perjury one of the fnilcwing Declarations: (CHECK ALL THAT APPLY) <br /> 1 1 have and will maintain a certificate of consent to self-;nsure for workers' compensation,21s provided far by <br /> I section 3700 of the labor Code, for the performantb of the work for which this pefmit Is Isst1 <br /> I <br /> C�---! have and wilt maintain woNers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of tine work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> 1 Gartiof: <br /> Policy Number; h^ d <br /> 1 certity thst in the p,xtormance of the work for which this permit is issued, I shall not employ sny person in <br /> i <br /> I any manner n as to become subject to the workers'compensation laws of CslbbOmis, and agree that if i i <br /> should become subjett to the workers componsetion provisions of S�vn 37()o of the Labor code,1 sh I <br /> iforthwith comply with those pravisiorns. <br /> bats: Y—/&-o! Signature: _ f <br /> Printed Name: <br /> 1 W,RNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS U?4LAWFtJt,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (siooga.), IN An01T1 C'f100 THE COST OF N 3706 Ot= THE I A80R Qp�ON'IH1 ERc5t, A.iTOfZNi=Y'S >~EE5,AND DAMAGES AS <br /> PfiOVi)ad FpR IN 9!E <br /> ro'e.S,5 '► (G 57 licensed atrthortzed repres+ntative),hsrelay <br /> avttttsri2+ <br /> u cSIe.S� I <br /> to sign this Sart Joaquin County Well Piorrntt bppllcation on my behalf. t understand this autharl;a00n is valid for <br /> ane (9)year and Is limited to the worst plan dated on the front pa3e of this application, <br /> E 3.17.2WO I MI <br />