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San Joaquin County EflVIMrttentai Health Department Unit IV Well Pem*Appbcatio�n7Supplern"t <br /> JOB ADDRESS: �L535 IS, k�-w� PERMIT SR# <br /> LICENSED CON'T'RACTORS DECLAkATIONL� Cd] <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(eornmeridng with Section 7000)of 1 h ision <br /> 3 of the Business and Professions Code and rrly license is in foil force and et1rP . <br /> License#: Expiration Dole`: J& d• <br /> Date: Lc1 b.� ContracWr: I f)r [ e E-1711 <br /> Slgnaturm / Witte: <br /> Printe4 � ae <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of tite following declm-Aons: (CHECK ONE) <br /> I have and will maintain a certificate or consent to asawnsura for workers'compensation,as provided for <br /> by Section 3700 of the tabor Code,for the performance of the wrodt for which this permit is issued. <br /> I have and will maaintaln workers compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the periommnce of the work for which this permit is issued. Loy workers'mrnpensation insurance <br /> carrier and policy numb` ere a rv, <br /> Carrier, l l 6 SdfPolicy Number: MS-- S <br /> 1 certify that in the pertomwic,of the work 4r which this permit is issued, I shall not employ any pemon in <br /> any manner so as to become subject to the workers'corrailensation laws of Californis.and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3740 of the Labor Code,i shall <br /> forthwith comply with those provisions. <br /> IExptration Date- Stanawre: <br /> Printed Marne: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPEmsATioN COV£RAoE IS UNLAWFUL,AND SHALT.SU10W ECT <br /> AN EMPLOYERTO CRIIWNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (;104,400.},IN ADDITION To THE COSY OF COMpe"ATiON,INTERM,A-rTORWy-3 FEES.AND DAMAGES AS <br /> PROVtDl_O FOR IN SECTION 3106 OF THE LABOR CODE- <br /> AUTHORIZATION FOR CiTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> L r�W 4�'` +�J1 (zianstu a afC-&7 licensed authorb*d representative), <br /> herebyauthorim(print name)—it <br /> to sign this San Joaquin County Well Permit Application on my tiehatL 1 understand this authorization Ib valld for <br /> one(1)yrw and is limited to the work plan dat*d on the#rant page of this application. <br /> 11-29-02 1 MI <br /> 6f22a04 <br />