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{r San Joaquin County nviror=tat HealthDepartmentUnit tV Viell <br /> JOB ADDRESS: IJ. PERMIT SR <br /> ICENSE.D CONTRACTORS DECLA-RATION (LCC?) <br /> t hereby affirm that t am Iicansnd under the provisions of Chapter g (commencing with Section 7000)of i <br /> Division 3 of the Business and Professions Cade and my license is in full force and effect. !!� <br /> License t �/n Exp pate- -' t 1�zo t? <br /> li Date- J�1 e Gontrecta:: �R�G{SIDn3 S� Nti tA7bT1/JL <br /> Signature: � Tlita: .-fjC.AT7YJn! F-1.,44,1tYbt2C <br /> Print Name: 2 LJ�1Iw�t?{�7i_ <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury ane of the following declarations:(check ane) <br /> 1 have and will maintain a certificate of consent to seifansure for workers' compensation, as <br /> provided for by section 3700 of the labor.Code,for;the performance of the=tiork for which this <br /> permit is issued. <br /> 1 have.and wile maintain workers'compensation insurance,as required by Section 3700 Of the <br /> Labor Code, for the performance of.the work for which this permit is issued. My workers' <br /> compensation insurance carrier,and policy numbers are <br /> I AMEA-ItA.3 !n#TE F3T1DNftL -� <br /> i <br /> Carrier:_!-,#EctAlztn tt BES Po{icy Number. d .3O- - `iS112 <br /> 41 GtlMa>R+a� ;t <br /> I certify that in me,performonca of the work far which this permit is issued, I shall notemploy any <br /> person in any manner so as to become subject to the workers',,compensatlon law of Callfomia,and <br /> I agree that if 1 should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith Comply with those provisions <br /> t, A{ I <br /> ..Exp.E}aie: (n1,3Vl L0 j D 'Signature: <br /> y <br /> Print Name: + I1} GYL1V� ✓Y� D I <br /> WARNING;FAILURE TO SECURE wORk{ER5'CORIPEKSATiON COVERAGE 7S UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER`f 4 <br /> CRIMINAL PENALT{ES AND CIVIL FINES UP TO 3500.000,IN ADDITION TO THE COST Of:COMPENSATION,INTEREST, <br /> AYTORNEY'S FEES.AND DAMAGES.AS PROVIDED FOR IN SECTION MS OF THE LABOR CODE. <br /> I <br /> (signature of c-67 r'PERPAII A1'HLICATiC3N <br /> tl pRJZRTiON FOR OTHER THAN C-57 SIGNING <br /> ` { Q 'g ,tensed authoriz mpresentay e)- <br /> 13 ,S\C�n <br /> ! hereby authorize(print name) - G16A to ' <br /> } <br /> t sign this San Joaquin county Well Permit Application on my behaEY. I uAdarstand this authorization is valid I <br /> for one year and is limited to.thework plan dated onthe front page o;this application. <br /> , <br />