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.,ar Joaquin Count mental Health'Cepartment Unit IV Well �ermit y.�t 0r,ry'tq+?y;d:.tena; <br /> JCL ADDRESS: N. PERMIT S a <br /> r o a o <br /> r OfDv 352 , <br /> LICENSED CONTRACTORS DECL.ARATIO /� ! <br /> herebyof rrrr that t am ii4o 'b HS& <br /> d under the provisions of Chapter S (commencing with Section 7000) of <br /> Division 3 of the Eus;r:ess and Professions rode and my license is in frill force and affect. <br /> l f <br /> License N (n =xp Date: <br /> Date_ S/� i l (y Conl'actor; hl2GGY51t3rJ <br /> Signature: TI',ie` _ {A7?Us 1 MI}� t1F67 <br /> Print Name: Ju1ttfP _ <br /> I <br /> WOPKER`S COMPENSATION DECLARATION <br /> '• hereby affirm under penalty of Perjury one of iiie fet'owing declarations: {check one} <br /> i <br /> I hive and will maintain a certificate of consent IT.self•fesure for workers,compensation, as <br /> provided for by section 3700 of the labor Code, for the pertornaiiCe of the'work for vrtiich this <br /> permit is issued, 3 <br /> I _t have and wilt maintain 4tiorkers'coinpenset n in strrance,as required by Section 3700 of the <br /> Labor£ode, for the performance of the work for tithich this permit is issued. 7v1 y workers' I <br /> compensation insurance carrier and pok-y nurnbers are' <br /> I 3}MEfct GRl+*} 1N7'�kt.,s,tR77ONfSt-. / <br /> f Carrier: SflFrc RI..Tt ut f Policy Number ( CX ) <br /> )i N5v, + CancC,A,jy <br /> I certify that to the performance Of the work ,or which this permit is issued, I shall not employ any <br /> person in any panne, so as to become sub ect ,o the vrorrers'cornperis ation law of CalPfornia,and <br /> agree that:f I should become suh)ec,to wo kers'ce npe :saUe l p,ov:sions of Section 3rD?of the <br /> Labor Codte I shall forthwith campy voth those nrovis ons. <br /> I Exp. nate• (pt, G' Z.G110 Signature: <br /> i <br /> Print Name: <br /> WARWNG FAILURETO SECURE WORKERS'COMPENSATION COVERAGE IS Ut LAV.'Ful,AND SMALL SUBJECT AN EMPLOYER TO (I <br /> CRIMNAL PENALTfES AND CIVIL FINES BP TCR S70ti;000,IN RODMON O THE 41OP.T OF COMPENSATION.INTEREST. <br /> _" <br /> p ATTriE;Nc.'S FEES.AND GAAtAGES AS P;�OVPOED FOR IN SECTION$703 OF litE LAsoR Cpv-E <br /> t1 i r7 ZATt��i FOR C)TFfiE t THAN G 57 SIGt 3tdG PERMIT APPLICATION <br /> �a (signature of C- <br /> Si P' ensed Fuz OnZ <br /> mrepres..r<tai��+et, I <br /> f hereby authorize(print nae) - - l t �t„Q� <br /> _ t5 ( ty✓ r to <br /> r <br /> sign this San JoagLlcounty Well PermitApplication on my beha' , 1 andarstand this autnorizatior. is—valid <br /> I <br /> fr,:r one y2ar a,;t'. is 11m;tad tc t^r work plan cacctS or. .nt� .,on,pr^g c;shis:iy,:lsca{ion. <br /> k <br /> 1 <br /> - i Rea:^,zmal <br />