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San,fosquin County E=nvironmental Health Services,Unit IV Wali Parrnit Applicaitldn Supplement <br /> JOB ADDRESS: -. 5— PERMIT SR#!+: <br /> LICENSED CONTRACTORS DECLARATION (.L,CCS) <br /> I hereby affirm that I am licensed under the prov19EGn.9 of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and Prafessiona Code and my license Is in full force and effect. , <br /> Uaense#: 7q.11 Expiration Date:_ S f 31 IG <br /> Date; <br /> Z 014 - -- Contractor: �aC: ��C c) t <br /> Title; <br /> Signature: 5i cf z h <br /> Printed name: Al Q 0 n"VI\) <br /> WORKERS'COMPF-NSATION DECLARATION <br /> I hereby affirm under penalty of parjury one of tie following declarations: (CHECK ALL THAT APPLE) <br /> _l have and will maintain a certificate of consent to self-insure for workers'cornpensaticn,as provided for by <br /> Section 3100 of the Labor Code,for the performance of the work for which this permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor on insurance ode, <br /> ._._for the performance of the work For which this permit is issued. My workers' coMp <br /> erisatcarrier and policy numbers are: <br /> Carrier: Policy Number: — <br /> I certify that in the performance of the work for which this permit is issued, I shelf not employ any Person in <br /> any manner so as to become subject to the workers'cornpensatipn lows of California. and agree that if 1 <br /> should become sublect to the workers'compensation provisions of Section 3700 of the Labor Code,I shah <br /> forthwith comply with those provisions. <br /> Date:_- 12 0 —Signature. "`�' <br /> Printed Flame: o n u v <br /> WARNING:FAJLURE TO SECURE WORKERS'COMPF-NSATION COVERAGE 15 EIPILAWFUL,AND SHALL SUl3.IECT <br /> AN EMPLOyr:R TO CRIMINAL PISNALTiC-S APIA CIVIL_FINES UP To ONE HUNDRED THOUSAND DOLLARS <br /> ($10%000.),IN ADDITION TO THE COST OF GOMPgNSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGLS AS <br /> PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br /> (C4T licensed&uthorixsd representative),hereby <br /> autharita � ��U y to sign this San Joaquin County Well Fernilt Application on my behalf. I understand this nut horfzatlan is valid for <br /> one(1)year and is Ilmitrd to the work plan slated on the front page of this appiicrttiarr. <br /> 5-17.20001 MI <br />