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62/19/2092 16:12 209490,34-j--l', FIFTi! FLLUR <br /> PAGE a3 <br /> F <br /> an Joaquin County Environmental Health Department Unit N Well Perrnit <br /> ApplicatFan Supplement <br /> B ADDRESS: l k?e4l, S'0 _ PERMIT Sly: <br /> LICENSED CONTRACTORS DECLARATION (LCDj <br /> hrsrehy affirm that l am licensed under the provisions of Chapter 9(commencing with Section 7000)of Uivislon <br /> 3 of the Bct <br /> Business and Professions Code and my license is In toll tome and effe . <br /> License#:� �/`� _ Expiration Date- <br /> Dal e <br /> ate:DahlContracbr, Ales f '-` /� <br /> r2/ � kiLL...iL L pati/' <br /> Sionat r . r Tide: i4�- �h�.f�6.1)L <br /> Prin d e: �C r C-4I/r7z.a f✓� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of Pe4ury one Of the lulluwing dedaratbns: (CHECK ALL THAT APPLY) <br /> I have end will maintain r3 Certificate of consetnt to self-insure fur workers'compansotion.as provided for by <br /> I tion 3700 of the Labor Code,for me Performance of the work for which this per'nnit is issued. <br /> V. t have and wiu,ndint <br /> sin workers'compensation Insurance,as required by Section 3700 of the Labor Code, <br /> for the Pertormanoe of the work for which this permit Is issued. Why workers'oompcnsalin i <br /> vttaurance. <br /> cairiw and Poli numbers are: <br /> Carrier: Policy Number: W 6 t/4 P l <br /> ✓ I certify that in the performance of the work for whk;h this permit is issued, I shop nod employ <br /> any manner so as to become subject to the workers'Compensation laws of shop no, and any Demon in <br /> should become Subject to the workers'compensation a that s 1 <br /> P provisions of Section 3700 of the Labor Code, I shat <br /> forihwitil comply with tho>;e provisions, _ <br /> Date:— D Z Signature: <br /> Printed Nam ,/ Cr-/,4,100 4_ Hdo <br /> WARM W,.FAILURE TO.SECURE WORKERS'COMPENSATION COVE-RAGE IS UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S"0,000.j,IN ADDITION TO THE COST OF COMPENSATION,INTEREST.ATTORNEY'S FCEs,AND pAr11A(3Es AS <br /> PROVIDED FOR IN SCCTION 37"OF THE LAAS <br /> t,�A <br /> 0/1 1�ut,a- <br /> //AA (signature ofC-571icerised wrthorked representative), <br /> hereby authorize(print name eche.,t S C ojL/o <br /> to sign this San Joaquin County Well Porn-it Appllcatlon on my behalf. I undwstand this authorilatlon is valid tar <br /> ono(y)year and Islimited to the work plan dated on the front page,of this appileatiwt. <br /> 1-2ti-02)?A1 <br />