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3 � <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Appllcatlonn Suppt rant <br /> JOB ADDRESS: M 2 oro Al ,,.,,-%l W-k.- ,w HERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL� CDJ <br /> I hereby affirm hist I am licensed under the provisions of Chapter 9(commencing with Section 7000)of 131vision <br /> 3 of the ftsineas and Professions Code and my ficense is in full force and effect. <br /> License tI: —T1042741 ' Expiration Date: 71311 z o f I _. <br /> date: -1 tZ-7 Contractor h ' (e• <br /> Signature; Tltie: y5� <br /> Printed name: <br /> WO 'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pe jury one of the following declarations: {CHECK ONE} <br /> _I hal a and will maintain a cartiFrate of consent to aatf4naure for workers'compensation,as provIded for <br /> by Section 3700 of the Labor Coda,for Ow parkmnance of the work for which this permit Is issued. <br /> I have and will maintain workers'oompensation imurance,as required by Section 3700 of the Labor Code. , <br /> for the performance of the work for which this permit is Issued, My workers'compensation Insurance <br /> carrier and policy numbers are, <br /> Canter. \-o `L'Q Policy Number:, .�.� c'.;) 0 <br /> I certify that in the performance of the work for whioh this permit is issued,I shall not employ any person in <br /> any manner so as to become subject to the woriters'compensation laws of California,and agree that N I <br /> should become subject to the workers'compensation provisions of Section 3704 of the Labor Code,I shall <br /> forthwith oomply with those provisions. <br /> Expiration Date: } D01 Signature. bAl1 r- <br /> Printed Name• <br /> WARNING_FAILURE TO SECURE WORKERS'COMPENSATION RE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRMBIAL PENALTIES AND CIV FNLS UP TO ONE HUMORED TMJaAND DOLLARS <br /> ("00,aWL IN ADDITION TO THE COST OF OOMPEMATION,W EREST,ATTORNEY'S FWS,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODe. <br /> A O ON R QTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> (@Vnat"oW W Itoeneed autharbad mpr'aeantativa), <br /> hereby auftwl o-(printmama) [.1Iti rUj t) N'& <br /> to sign We San.ioaqula County Well Penmlt Apptkalton on my bMraif. I undershm !Ills authorbatlon Is vaitid fvr <br /> one(1)year and Is Itrnrbrd to dw worts plan his on the front page of thin application. <br /> a-29-02!MI <br /> FrID 24-02-00 i <br /> bat% <br />