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FIFTH FLOOR <br /> PAGE 04 <br /> Fhar0y <br /> uin County Environmc F HOCRh Departmc Unit Well pp�it ppplica�n Suppl <br /> ement <br /> JOB ADDRESS: ��PERilA1T S;R�#; j LICENSED CONTRACTORS DZCLARATSOc� LCDm ttk"tt I em IiCensed under the provisions of Chapter 9(commencing with Section 7000)o <br /> ess and Professions Code andmy licenso is in full fonds and offect. <br /> License>;�: Expiration Dat <br /> e.Data: 2n 0 Contractor: O VU-Jk 1. <br /> Signature: l� k i <br /> e Title:�-��, <br /> Printed neuro: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby sf)trm under ponalty of perjury Orta of the following declarations: (CHECK OWE) <br /> I have and will maintain a certificate of consent to aelf incuro for workml compensation, as provided for <br /> by Soction 3700 Of the Lebor Code,for the performance of the work for which this permit is issued. <br /> 1 have and tail)maintain warkOm'compensation insurance,as required by Section3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. MY wOrketV compensation insurance <br /> carrier and policy numbem are,, <br /> Carrier; G'V` Y,•-VPoficy Numbar: <br /> I certify that in the performance of the work for which this permit is issued, 1811911 not employ an <br /> rson <br /> any manner so as to become subject to the worlcer8'componsation latus of Caff rnia, and agrea tthhat if I in <br /> should bocome subject to the workers'Compen <br /> forthwith comply with those provisions. sation provisions of 3oction 3700 of the Labor Cod2,1 Mall <br /> Dato: coo Slgnaturo:_ .L 1 -K <br /> A <br /> Printed Mama: `-C" 2 t S c� l . V_.4e_ <br /> WARN UG:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AkD SHALL SUsj2CT <br /> AN EL^PLOYCR TO CRIMINAL PENALTIES AND CIVIL FIRES UP TO ONE HUki?I�D Tt{�0q�+g DOLLARS <br /> (5100,000.1 IN ADDMPTL <br /> 3TION TO THE COST OF COEoSATION,INREST,ATTORNEY'S tr'!`ES,AND 3ES q <br /> PROVIDED FOR IN SECTION 37116 OF THE LABOR COQ. <br /> AUT14ORiZATION FOR OTHER THAN C-57 SiGNING PERlI,717 APPLiCA T[ON <br /> 0 <br /> 1. l t <br /> — Isi9e4ture ofC-57 liccnsod emMoriiod raprosontathro), <br /> hereby authoriao(print name)— fo-�A Y\ � ,t <br /> to sign this San Jonquin Co,rnty Well Permit A0011cction on my behalf. 1 undomtend this Cuthor4atlon Is Vclid for J <br /> ono(4)Yocr and is limited to the 17orh plan dated on the bent page cd this oppliceno L <br /> 13-39-031 Mt <br /> ZO-d d10 : Z1 Z0-OZ-daS <br />