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San Joaquin Gount//y��Environmental Health Department Unit IV VVell Permit Applicafitiom supplelmp nt <br /> JOB ADDRESS: 5?r—&1___�P8RMIT SRO:-- <br /> LICENSED CONTRACTORS DECLARATION I;L� <br /> I hereby afliirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Div sion <br /> 3 of the Business and Professions Code and my license is in foil force and effect. <br /> Limnse#:_G'S 717;1Q Expiration Date: <br /> Date: `1 Can tor, ✓LGI� _ <br /> Signature: Tide: - <br /> Printed name, <br /> WORKERS"COMPENSATION DE=CLARATION <br /> I her aby affirm under penalty of perjury one of the fallowing declorritions; (CHECK Q NF) <br /> I have and will maintain a corRmte of oomsferd to oelf•insure far%wrknrs'compensation,as provided f)r <br /> by"lection 3700 of the Lalaor Code,for the performance of the work for which this Dermit is issued. <br /> I hmvo and will tttdintnin wom.ers'compensation insurance,as required by Secfton 3700 of the Labor Cc tie, <br /> for the performance of the work for which this permit Is Issued. My workam'eompnnsation insurance <br /> canter and <br /> 1policy <br /> nnumbers are: <br /> Carrier:ry�/�c�j�/4'/�i � "_ Policy Number: _ <br /> I certify that in the performance of khs work for which this permit is issued, 1 shall rut employ Any persoi)in . <br /> any rrimnnrerso as to heeorlla subject to the workers'compensation laws of CAlifarnia, anti agree that if I <br /> should i vcome subject to the workers'Compensation pmvitlbris o`Seotian 3700 cii7 the L Libor Ccde, I s call <br /> forthwfth co ply Ith those provisions, <br /> Date: Q Siignature: — <br /> Rninted Name. <br /> WARNING.FAILURE TO SECURE:WORKERS'COMPENSATION COVFAAGR IS UNLAWFLIL,AND SHALL SUBJI cCT <br /> AN EMFL OYER To CRIMINAL PENALTIES AND CMI,FINES UP Tq ONE HUNDRED T14OLISA,NII DoLLARs <br /> 1S7p0,{160.),IN AUDITION TO THE COST OF COMFENSATION.INTEREST,AT ORNRY'S KEES,AND DAMAGES,kS <br /> PROVIDED FOR IN SECTION 37DC OF THE LABOR CODE <br /> A HORIZ,ATT F R TH THAN C�S7 SIGNING Pr7-RMIT APPLICATION <br /> I' {signature ofC-6TlicnWd duthorized rapresentalirbh <br /> hereby authorize(print name} -v Id 1,� <br /> to sign this San Joaquin County Weil permit application on 440halt 1 understand this a(wdhorizatlop Is valid f;r <br /> Ones(1)year and is limited to the work plan dated on the ftnt Tag®of this app[IcaMan. <br /> 8-29,021 MI <br />