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R <br /> Ff EE <br /> San Joaquin County Environmental Health:brvkvs b;it N Well PeTtnit At1plpp1 <br /> i <br /> JOS ADDRESS:— <br /> i <br /> s <br /> LICENSED CONTRACTORS DECLARATION "C : <br /> C <br /> I hgmby of irrn that 1 am iicensw under tiro pfovisior:s of Cn Ater Q(commencing with Sedian 7000)a vvision <br /> 3 of tile SLIGIness and Profassions Code and my Itcensc Ls ir futt force and effacL <br /> eviratf Date:_� —3A r d.3 <br /> Dat©_ Contractor r r <br /> SlgnatUre: 7itia: ! tN <br /> WORKERS'COMPENSATION DECLARAInON � <br /> 4 <br /> I hereby arfrn under peney of perjury one of the following e'ftrsuons: (CHECK ALL TrfAY APPLY) <br /> ensetion.as <br /> - avlded for b <br /> I have and vviil maintain a c�.r#ificat&of consent is self ire re for <br /> workers'cai3 <br /> rd <br /> { Section 3700 of the labor Code,for the perforinanca of tha work far which this perrnit is issued: <br /> f t nave end will maintain workers'compensation insuran a,as required by Beckon 3700 of the labor Code, <br /> for the performance of the work for which this pOfmit is i ued. 8riy W0rknrs'coML 6nsS0w lnsura= <br /> i <br /> certser and paricy numbers arm. <br /> 4 carrier�J - J�Gr_ patiry Number: J.S <br /> __f ccdify that in the parformence of Me work for wtri h thi permit is issued, 1 $halt not employ any parson in E <br /> ony manner So as to become stl0ject to MC workers,oarnperiUdam Jaws of California.and agree that it 1 <br /> shouid become subject to the workers'compensallon pr visions of Section 3700 of the Labor Code,E$hall <br /> forthwith comply with tho68 proViSionS. <br /> [$ate; Signature; <br /> Pruned Name: <br /> WARNING:PAU-URE TO SECURE WORKERS'QCMPEN3"014 COVERAOt 13 UNLAWFUL,,,AND SMALL Stlt3jecT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CiVrL FRIMM=3 TO Olft;HUNDRM THQUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPENSATION, AiM ST,Al3ORt4fY'S MES,AND DAIylA[3ES AS <br /> PR0%t DED FOR IN SECTION 3766 OF THE LABOR CODC <br /> f F <br /> C�6� ICC j B {C-57 ilcenscd btlttSorizad reprs��ntatlYa),here&y <br /> audiorizs 7 <br /> to sign this Sari J*wvin County Well Permit Aepllcation on r behalf. I underata[nd this ziuthofixallnn ie va9d toi <br /> one(1)year snd is lirn[Nd to the watk plan&Wd on the franc gwgo of this aPPACatiarr, <br /> x•17.20001 MI__ ,. „ --_ <br />