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AUQ "IL I I UL:U4p NnnrlalllpgradiP-nt 530F'7730bb p.1 <br /> San.Joaquin Co"rity environiffental Healy <br /> Departrr�nt <br /> �— N 1N8F1 I�erltlit alaplica�orl Su le <br /> JOB ADDF�SS: JL..� l Pp Inerttar <br /> ��� PERtId1T SR# <br /> SCC- -c ' <br /> LICENSED CONTRACTORS DECLARATION <br /> hereby affrm that I am licensed under fihe provisions of Chapter s(Commencing with section Division 3 of the Business and Profrassions Code and my license i9 in foil <br /> t-� n Fflpp)of <br /> License#: tl;a o q and effpm <br /> �. <br /> Exp <br /> ©ate: � ; ' , !i � � <br /> ContraCtol; �1��I <br /> Signature; <br /> TTt <br /> Flint Name: �M V 1 <br /> WORKERS COMPENSA I*1 DECLARATION <br /> I hereby affirm under penalty of pefury one Of the following dedarations: (check one) <br /> I have and wril maintain a certificate of consent to self-insure for worke <br /> Provided for by section 3700 of the labor Code,for the perforirlanae of rsitle' wr P far on, as <br /> this <br /> Permit is issued. <br /> I have and will Maintain workers'o�Rensa�tian insurance, as required Labor Cade,for the PeftnItV ince of the work for whic;h this q d bl+Section 3TO0 of the <br /> Compensation insurance Carrie and policy numbers��� permit is issued. telly War$mrs' <br /> Carrier.lti� � Policy Number, <br /> 15�0 <br /> Certkfythatin'tirepeftm`WCe Of the work for whish chis , I she U <br /> person in MY manner so as tQ become subjectto the penmrt Is issued" t shall not employ any <br /> agree that if I should woricers�cortrpen9Mon law of California, and <br /> �' ' to m'�mpensation provisions of Section 3700 of the <br /> Lobar e,j shalt frartr can"Wilh those3 prnvis' ns. <br /> gyp. Date: f - <br /> . <br /> Print Name,- <br /> wARMNI .r A um ToSECURE WORKMW ceaerP rrsnTaoN <br /> cr�rllMlr L ew'ALTMAM c mL"Wes up ro 1a0.000 covetoGE is Ur'e#.AyYFUL AND SMALL sUaJECrAN E�fPt oY�f Tp <br /> iORM 1^9 FSS,AND DAMAGES A8 FRCMt3Efi FOR M rItON Ta THIS cesIr OF COOPEPMATION,INT�gT <br /> AT , <br /> 3t-=Off$706 OF THE LABOR ootalr_ <br /> T D 1 OTHER THAN C47SIGif1 ING nmrr <br /> i' APPLICA'1'IpH <br /> he aLd1wrbe(print aane) IC (8l9nMUM OCC-57 cena4 aII/\ t <br /> C.I'G1G{L Ef�i r rmaj..)s <br /> sr9m this Sall Joaquin vourrty Well Permit Appncdtim;ora iae v 'to <br /> for one U half. 1 uadomtond 11ft auftwi�n is Wam <br /> Year and�a lirnitetl to the Plan anted art the ftgnt,Paye Of tats application. <br /> ane Asa IUM? <br />