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�. .. <br /> San Joaquin County Environmental Health Department Unit IV Weill Permit Application Supplement I <br /> I hereby affirm that 12m licensed under the provisions of Chapter 9(commencing with Section 7D00)of Division <br /> 3 of the Business and Professions Code and my license is in tun force and effect <br /> License#. �Q 57,9 L4(7 -7 Expiration Date: (C_)1� I'/1) Cry <br /> Date-. "1 L!- 0 (o contractor <br /> Signature: --- Tltle: ,� e4,t�,V —IT <br /> Printed name- <br /> ! WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penally of perjury one of the following deciamtions: (CHECK CNE) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for <br /> k by Section 3709 of V%Latu Code,for the performance of the work for which this permit is issued. <br /> '1 have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'Compensation insurance <br /> carrier and policy numbers are: 1 <br /> Carrier. 1. _IA- Policy Number. J5� IOC <br /> I certify that in the performance of the work 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 Calitomia.and agree that j{1 <br /> should become subiectto the workers'compensation prnvisinns of SPrSinn a7nn of the I,%K^e r_nein I eKnll <br /> fortlwvith comply with those provisions. <br /> 1 <br /> Expiration Date: j 6!2 Signature: <br /> Printed Name- <br /> WARNING:FAILURE TO 8E"RE WORKERS'COMPENSATION ERAGE IS UNLAWFUL,AHD SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES IIP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature afC-67 tiransed authorized repr"entativa), <br /> hereby authorize(print name) o' /1dr3�-f�- gYL�L�]J?L, rWiLll <br /> to alga this San Joaquin County Well Permit Apphcalfon on my behaff. 1 understand this authorization is valid for <br /> one(1)year and is Itrntted to the work plan dated on the front page of this application- <br /> 3-29,,021 IM <br /> EHb 29.02-001 <br /> 622!04 <br />