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Sbrt doaquln Coo tty F-nvirehl'riaiitsal Hemith Departrnelnt chit IV Well Permit Application Supplemant <br /> PERMIT spUk. 2 <br /> LICF-NSED CONTRACTORS DEdLAWION (LCD <br /> I hereby aflirh,that I am licensed undorthe provisiohs df Chdpter 9(tbm�enrArig with Sectioh 7000)or division � <br /> 3 of the SUsinesd and Professions Gods iarld my lieense Is ih full force and affect, <br /> , <br /> L•�nse#: ��� -�-7�T =�xlyftstibn l�attl' �•�f'�r �? � <br /> �S! illt° <br /> bate! /P/ bi <br /> Signature. `title <br /> Printed name: <br /> WORKER'COMIREMATION DVICIJRA1111014 <br /> 1 horeby affirm udder penalty of perjury one of the following declarations: (CHECK ONE) <br /> I havo ohd will maintain a certificate of consent to self-insure for'worker$'compensation,as provided fol' � <br /> by Secflon 9700 of the Labor Code,fotthe pl:rforrnando bf the work for which this permit is issued- <br /> have shd whl maIntaln workets'compensation 160Urahce,as required by Seotlon V00 of the Labor Code, <br /> for the pied &nxince of the work for which thit permit Is issubd. My�rorkeml ebrnpensatiort ihsuronne -in <br /> carrier and ppuOicy hUmbbeer`srare-, <br /> Car•tlen 1 -; i, � �kI d._ Policy Number: <br /> I certify that In the performance of the Work for which this permit It isdued, I shell not employ tiny person in <br /> any mariner so as to berme subject to the Workers,compensation lmwa bf Callfomia,and agree that if I <br /> should become subject tb the wotksrs'compe on prnvlsions otgtulioh 3700 of the Labor Code,I shall <br /> forthwith comply With those provislorW. <br /> �Xplratlon deto: 12JI 101_srgrtature: .` <br /> prin4ltd Name:.�..�� t` <br /> WAgWINOI FAILURE TO SLOURE WORKUR91 COMPENUTION 00V0AGE IS UNLAWFUL,AND SHALL SUBJIYCT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINIS 0P TO oNB HUN]RED`CHduSAW doLLARS <br /> (J�loo,bou.),IN ADOMON TO`rH9 COST OF Cbl PP-NSATION,INTEREST,ATTORNIEtrs FtEs,AND nMAWES AS <br /> PROVIDED FOR IN SBCTION 3106 OF THE LABOR CW5. <br /> ANTHORIZATION FOR OLN THAN c-v SIGNING PERMIT APPLICATIONIV <br /> � <br /> 1, GtJf(iJC—� ., txtg sture otc Head�uttrtlrJzatJ tapresari'tatlgQ), <br /> { <br /> 1�Y�by authdrlfa(pr <br /> to sign this San Jda4LIin CoUnfy Well Permit Applicatibn on niy hwhalf. I d thls authorization Is VaJld for <br /> 4 <br /> orJe(1)year and Is Urnitad to the wank phin dated On the front p8ge of this 2ppliCgtien. <br /> $r�9-o2!Mi <br /> 13FID 79.0 -0at <br /> G/22/tl4 - <br /> 9E/2'd 2S0'ON '0NI`H0310ZIIAN3 X3dd Wd02:2 L002'6Z'100 <br />