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08/201'2010 14: 50 510-633-5646 NINYO AND N10ORE PAGE 02108 <br /> 08119/2010 TVG 12:,62 FAX 2.094683433 S C ERD 2002/002 <br /> San Joaquin County Environm9mml Hoalth Dollmrtmont <br /> WELL& BONING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS; �Cf 141re d k'� �yacx ro.,� "q PERMIT 3R <br /> LICENSED CONTRACTORS DECLARATION (�D} <br /> hereby affirm that I am llcenaed under the prOvislone of Chapter 3 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code at)d my h0PxS9 Is in fUll force and pct, <br /> License#: _ C G-7 710$ Exp Date: 3/ <br /> Date: ���i� _ ^�Contractor Ver r 7e�. a <br /> Title: <br /> Print Name:_ GL800 5.5 <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm unoer penalty of perjury one of the following declarations:(check ore) <br /> I have and will maintain a certificate of consent to self insure for workers' compertsatlon, as <br /> provided for by Section 3700 of the Labor Code, for the performance-of the work for which this <br /> permll is Issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Laf?or Code, for the performance of the work For which this parmlt Is issued, My workers` <br /> compensation Insurance carrier and policy numbers are: <br /> Carrier: J� ((�� In-sLvr,,c < r` �_ gg <br /> �LL� G *3� y Policy Nurrtbar:• �7�UV 11�� <br /> f certify that in they performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so gs to become subject to the workers' compensatlon law of California, <br /> and agree that if I should become subject to worksrs'compensation provisions of Section 3700 of <br /> the Labor Code,I shall forthwith comply with those Vrovisions. <br /> Exp.Date: Signature, /�. . <br /> Print Name: <br /> WARNFNCi FA$LURE TO 9ECURE WOOKERS'COMIPlSATION COVCRAGS 13 UNLAWFVL,AND$MAUL SUW%T AN EPAKOYER TO i <br /> CIUMNAL PENALTI"AND CIVIL MMrS UP TO$100,W, IN ADDITION TU THE COST OF COMPMSATION, tNTEREsT, <br /> ATTORNVI FEW,AND OAMAGM As PRomw FOR IN SECTION 3708 OF THE LABOR CODr:, <br /> AUTHORIZATION FOR OTHER THAN C•57 SIGNING PERMIT APPLICATION <br /> 1. , ._ (signature of C-67 Iloensed authorized represent ative►, <br /> hereby authorize(print name!SFisSen , to sign this Salt Joaquin County Well & Boring Permit <br /> Application an my behalf. I undnratand thle authorization Is valid for one year and is limited to the work <br /> pian dated on the front}gage of this application. f <br /> MHP 2"l O'7�1M 0 <br /> 1'rTt6 A6hM1r APP <br />