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Oct 08 01 03: 37p ESR-SRC SIGS644501 p, 3 <br /> r06/20I20A0 09:52 209,''"433 PIFTH FLOOR I PAGE 03 <br /> s{• - - ; <br /> FILE COP <br /> San Joaquin County Environmental Health-Services,Unit IV Well Permit Application Supplement ' <br /> .SOB ADDRESS: V OA\ U ��+tvJ�c��� Pi.`�• _ PERMIT SR#: <br /> �v-\rec.�i-�Odti Cf't <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Susiness and Professions Cade and my license is in full force and effect. <br /> license#: 1.3(,3 a-4- Expiration Date: Aro, oZ <br /> Date: t4��9�0� Contractar: .�GC:t:oN SQMQLilV1 fNC, <br /> Signature: —Title: C i - <br /> Printed name: M 1>�� iz <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decfaraWrm. IWECK ALL THAT APPLY) <br /> _t have and wiV maintain a certificate of caasent to self4risure for workers'compensation,as provided for by <br /> Section 3700 of the Labor 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 37ao of the Labor Code, <br /> for the performance Of the work far which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are. <br /> Carrier. tA-thx u t/k w—rte Paiicy Number_-W t% •• '[3 " p a-L3 3 9-of i, <br /> I certify that in the performance of the work for which this permit is issued.-l shack not employ any person in <br /> any manner so as lo become subject to the workers'compensation laws of California,and agree that if I <br /> should become subject t4 the workers'compensationpry,1i fans of Section 3700 of the Labor Code,I shall <br /> forthwAh comply with loose provisions. <br /> Date: td"\O t Signature: <br /> %�J.f <br /> Printed Name: C eY <br /> WARNING.FAILURE TO SECURE WORKERS'c0 MiPFNSATION COVERAGE IS UNLAWFUL,AND SHALL SU13JECT <br /> AH E%pLoyeR TD CRINNAL peKALTtES AND CIYtL FlUn IIP 70 CNE muNDR>EU TKOUSANR 12OLLAR3 <br /> Illov,000j,IN ADQIT"TO THE COST VF COMPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3TQG OF THE LABOR CODE. <br /> t. w4s- <Ac e y (C-57 licensed authorized representative).hereby <br /> ae ttort�oe <br /> to sign this San JoagUir'County Well Permit Applieation on ray behalf. I uridenstand this authorization is valid for <br /> one lf)year and is limited to the work plan dated on the Maps a of this application. <br /> t <br />