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- tla► ived Fay: 0812410g ni9P)rlFax station; All Ve_1 kbandonient `� p,04 <br /> Sen Joaquin County Environmental Health Department t.nit IV Well Permit Application Supplemental <br /> JOB ADDRESS; j, 5 I C l ,' A)WWPE RMIT 5R# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 11-1 t----fk�,-4_-J w.Ktvi 4IIV t"%#T1`1wFw yr*1`AF"` 0(""1I's 401f1 "d "Ili,.3o�.ltan�7000)yr <br /> Division 3 of the <br /> �Susinoss and Professions Cade and my lic tnse is in full force and effect. <br /> License#: f aMS9 E cp Date: 10 1 ZA C10 10 <br /> Date: Contract `�XA_ c„„�� o n <br /> Si<jnatur Title. r Ir <br /> Print Name- "� AC&C.i 0� <br /> WORKER'S COMPENSATIOtf DECLARATION <br /> I hereby affirm under penalty of perjury one of the follow ing Ieclaratlons:(chock o ne) <br /> I have and will maintain a oertlficato of consent to s If-insure for workers'compensation,as <br /> provided for by section 3704 of the labor Code,for t le performance of the work for which this <br /> permit is issued. <br /> heIVA and*%maintnln wr rkPn'mmlwnsation inst�ranca. es required by Section 3700 of tho <br /> Labor Code, for the performance of the work for whish this permit is issued. My workers' <br /> eompenswion Insurance carrier and policy numbers are: <br /> Cwarrisr: A( - Policy Numbir. a I� - <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to th=workers'compensation law of California,and <br /> agree that if I should become subject to workers'co npensation provisions of Section 3700 of the <br /> Labor Code, I shall fortirnith comply with those prov cions, <br /> Frp,f)atn:, L+ i .. S3gnatu <br /> UL <br /> Print Name: ib�1 CIC L <br /> WARNING:rAILURE TO SECURE WORKERS'COMPENSATION COVERAGE tg UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FMS UP TO M0,400,IN AIN MON TO THE COST OF COMPENSATaou,INTEREST. <br /> ATTORNE"I1E3,AND DAMAGES AS PROVIDED FOR IN 3EC-10N 3704 OF THE LABOR CODE, <br /> AU HORI TI N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. f (slanaturr-of C-57 licensed authorized nipresentative), <br /> hereby Authorize(prin ame) ,to <br /> Sign this San Joaquin Wrlt Permit{Ippilca oowni )ohalf. I undomtand this authorisation Is valid <br /> for one year and Is limited to the work plan dated on the Iron'page of this application. <br /> tt17A107J1rIF <br /> pp2sos titer <br />