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SlawJoagym-County EnvircinmentAftalth Services, Unit IV Well PermitApplica upptement, <br /> .tOS:WEIRESS. �+Nsu� /1�. Cust Sn.n - f� 'PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 81 '7S'Y $ — ExpiratiomDate: bi-31 •0'1 <br /> Date: D6 .,77 'Cl° Contractor�5 A.t4&A,C-'t 2).'4�u .«G yt luc5�/�tt <br /> Signature' v/� Title: 6 ew.XA-t. G"f�b+'ttt <br /> Printed nam r Z'a•t7t4 A a f7T~ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided;for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> ✓ I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code. <br /> for the performance of the work for which this permit is issued, My workers'compensation insurance <br /> carrier and <br /> policy numbers are: <br /> Carrier: /yr.4/•-7')=6AA �r5• Policy Number: 21 W dVILIN 7!3 I <br /> _ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Lab ode, I shall <br /> forthwith comply with those provisions, <br /> Date: O 6-it -a 6 Signature: <br /> Printed Name r c.4-4-^g 4- <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> r .0 I cw ,t' n' "' 'o� � C-57 licensed authorized representative),hereby <br /> authorize m 1144 /Z0/2,,D of CA I C. <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> 5-17-2000/M I <br /> D0 39dd 600-U H13I3 EE6£89060Z vs:L0 000Z/5Z/0i <br />