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San Joaetuin County Envitern emal Health Department Unit 1V We41 Permit Application Supplements) <br /> JE}B AODRESS: O V t . ..... PERMIT SR# _ vl. d( <br /> N Pr <br /> LICENSED CONTRACTORS DECLARATION (L p} <br /> t her Stigler that I am licensedthe provisions of cls r 5 q ring with on 7 } at <br /> Division 3 of the Bustnests and Fres ons Cade and my license is in full force and effect. <br /> Ocense# E:xp'Oate 1 2 t 2 <br /> Date Contractor C1kC t7 <br /> SigrsaMrs ___------__W Title <br /> ------ S ICJ 1_ h#Fit1ltt{ 1 ?C <br /> print <br /> WORKER'S COMPENSATION DECLARATION <br /> nerabi,affirm under penalty of perjury one of the following declarations {check arae} <br /> l have and will maintain a certificate of consent to ;insure for womers'compensation, as <br /> provided for by section 3700 of the tabor Cade for the Wormanice of the work for which this <br /> perms is issued <br /> i have and will maintain workers compensation mauaance.as required by $&Man 3700 of the <br /> r far the performance of the work for which this permit is issued Aly workers' <br /> compensation insurance carrier and policy numbers are <br /> f4M11.:i G.aa+J iittT`E . <br /> Carrier: LI AJ IF5, Policy Plumber: <br /> t certify Malin the performantae of fief work for which this permit is issued: i shall not employ any <br /> person in any manner so as to become subjectto the wo " law of Cat` a. and <br /> aWw that it I should become stab to workers' cam ration provisions of Section 3700 of the <br /> Labor Code, I shall forthwith Comply with those p m$ions <br /> Exp. Date,_v LUQ Signature's <br /> Print me: <br /> W APN!NO iAtLURE TO SECVRE COVIAXOP t$l NLAt b"F.UL.AND SHALL VcT AN EMPLOYER T9 <br /> CRIMINAL TIES ANO Ctim,FINES'UP TO anti.. ,is AtilliftOW TU THE COST OF COMPENSATION.INTEREST <br /> ATTORNEYS PEES,ANO DAMAGES AS PROVIDED FOR IN ItfO tON 3705 Of THE LMIOR CODE <br /> U "TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1. 1 ---�--- signs a nP C b7 livens c4 author' ed re r en 'va} 1, <br /> hereby authorize(print name) <br /> sign this San Joaquin bounty Well permit Application on my behalf. l understand this authorization is valid <br /> for one Yost and is limited to that work plan dated on the front page Of this applic:atiom <br /> FrMkn DrM <br />