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E.R.R.G <br /> JLL-15-2098 10+05 <br /> E. r, • <br /> I 415395999 p, <br /> 415395999 30 <br /> FrebtjSha <br /> County Environmental Hearth Department Und IV Well Perrnit ApppceFen Seopplemerrtal <br /> 4J1 A PERMIT SR# <br /> CENSED CONTRACTORS DECLARATION I <br /> 0 (LCD) <br /> t I am licensed under the provisions of Chapter 9(commencing with Section 7000} of <br /> usiness and Professions Code and my license is in full force and effect. <br /> License#: �l°I�,eIQ <br /> Ezp Date: Vj • ?u1. 'kupq <br /> Date' • {C, �pp� Contractor; I <br /> Signature: /WU T'dIL: 5 �G7 /7�ii7QG r <br /> Print Name: <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I nave and will maintain 2 cermcate Of consent to self-insure for workers'compensation,as <br /> provided for by section 3700 of the Iabar Code, for the <br /> permit is issued. performance Of the work for which this <br /> I nave and will maintain workers'compensation insurance, as required by Saction 3700 of the <br /> Labor Code, for the perfermanca of the work forwhich this permit is issued. My workers' <br /> compensaticn insurance carder and policy numbers are: <br /> Carrier:I ZU y 1 C h b <br /> Policy Number. I.eJC �zs 9855-6vJ t Ger lfy Thaan <br /> t in the perfcrTnee of the work for which INS permit is Issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of Galifilmia,and <br /> agree that if t should become subject to workers' compensation provisions of Section,3700 of the <br /> Labor Code,,I/shall fonhwilh comply with those provisions. / { <br /> Exp, Date:_ Y 'l`Q Signature: <br /> Print Name: �i�QCT4f�LL <br /> WARNING:FAILUNE TO SECURE WORKER-5 COMPENSATION COVERAGE l5 UNLAWFUL ANO SHALL SUBJECT AN EHPLOTER To <br /> raiMINAL PENIALTIES AND CIVIL FINES UP TO='100,000,IN AOOITION TO THE COST OF COINFE NS ATION,INTERFST. <br /> ATTOMNEY%FEE$ANO nAMAOEg�PROVIDED POR IN SECTION 1706 OF THE LABOR COO E, <br /> r <br /> AUTHORIZATION F,QR PTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1• '�!J!/oT77� <br /> ` A _ ' (signature of C-571Ktmsed autltar'Ized represemalire), <br /> hereby aurize tho (print name) <br /> m <br /> i9e1 ; Q f n tJla n g�� <br /> Sign thi6 San Joaquin county Well permR APplfcatran on my behalf. I understand this aufhorizafian is Valid <br /> for one year and is limited to the work plan dated on the front pogo of this appGcstion. ' <br /> a2 Mur <br /> EH0T001 14NOt <br /> hF-',y v�gryyipvp <br />