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9 <br /> I <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Applicatito.,n. Supplement <br /> JOB AbDRESS: R149Ct (/,)S 126 PERMIT SRIF: 1 , 3 <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that i on 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 #: 1 ��� 1 P �? Expiration Data Q f> l l p (( o <br /> 1 Date: _ Contractor. C en � r t- Ill <br /> i <br /> �� � v' <br /> Signature= Titl <br /> �,/� � , 'LJ! ' e: ��� <br /> Printed name: 9 i a, <br /> WORKERS' COMPENSATION DECLARATION <br /> i <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _ i have and will maintain a certificate of consent to sell-insure for worker' compensation, as provided for <br /> by Section 3700 of the Labor Code, for 1w performance of 11m work for which this permit is Issued. <br />' yl have and will maintain workers cornpensation Insurance, as required by Sermon 3700 of the Labor Code, f <br /> for the performance of the work for wn ch this permit is issued. My workers' compensation insurance <br /> carder and policy numbers are: (� p <br /> Gentler: LJ ! U ��� I <br /> cr 1 G ) \ ( Policy Number <br /> I certify that in the performance of the worts 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 Sedan 3700 of the tabor Code, l "I <br /> forthwith conpty with arose provisions. <br /> �' f signature. 1 <br /> Expiration Date: N � l 1 �� <br /> i <br /> Printed Name: �{ (L I L•( � � f ') <br /> i <br /> WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SUBJECT <br /> AN ENWL.OYER TO CRIAl1NAL PENALTIES AND CML FINES UP TO ONE MMORED THOUSAND DOLLARS <br /> (t10o,0aD.), IN AnDI TION TO THE COST OF COMPENSATION, WIEREST, ATTORNEYS FEES, AND'DANIAGES AS <br /> PROVIDED FOR IN SECTION 37011 OF THE LABOR CODE. <br /> AUTHORIZATION FORE OTHER THAN CZ7 SIGNING PERMIT APPLICATION <br /> -�� ! LL. V �'_f L0LL�`C� % V 1-r (signature o(CJ57 lianaed authorized re mser"ativel, / <br /> f <br /> hereby authori e {printmmei =-� �- I �- �._( ryl �� C �l�_ �j�L�J;( `f <br /> I <br /> 4 to sign this San Joaquin Courtly well Permit Application an my behalf. 1 tnlderawit! this aodronzahon is valid for <br /> one (1) year and is limited to the work plan dated on the front page of this application- <br />�: E49A21IN <br /> i <br /> END 79.02-001 <br /> 6122/04 <br /> L` <br /> f <br />