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. Cleo uc. .,i ❑1 is ,1 i• i `tll: <br /> P'AM1:I. Ci_e tt3 <br /> ISven JoayulnCnntyEnvironmental!HeaBh Department Unit IV Well fJerm!App(icatian Supplement <br /> JOB ADDRESS: SDO W sY�F6y4J .PERMIT SR#: <br /> I <br /> LICENSED CONTRACTORS DECLARATION (LCI]j <br /> I horreby affirm that I am licensed Wide,thn provisions of Chapter 9(ootnmencing with Section 7000)or Divisior, <br /> 3 of the Busrnu'1ss and Prof eessf ns Cohn.and my license i* in full force and ffect <br /> �'-� AP( anon Uate; <br /> Datr_:_-_ _Contra toe r W_Del' <br /> r � <br /> Si®nature:_ 11 Tufa: <br /> Printed name: <br /> WORKERS" COMPENSATI DECLARATION <br /> I hereby affirm under penalty of padury one of tho foflawing declarations: (CHECK ONE) <br /> `1 have and will maintain a certtcsta of consent to self-insure fer workers'compensation, as provided for i <br /> by Section 3100 of the Labor Codo, for the perforrTiance of the work forwhich this permit Is Issued. <br /> I have and will maintain workers' cornpensatlon ineurance,as required by Section 3700 of the I rlbor Codc, <br /> for the performance of the work forwhicll tnis permit is issued, My workers'�' compansatirn insurance <br /> carrier anttpolioy numbs aro: �1� <br /> Carrier: C f`-` q 3 <br /> ---�. Palley Number: <br /> I certify that In the performance of the work for which this permit is issued, I shall not employ any person irl <br /> any manner so as to become aubjaet to tho workers' Compensation law,:nr Califom a, and agree that if I <br /> shaved becwne subject to the workers'compensa inn provisions of Fn ilk n 3700 of the Labor Cede, I shall <br /> forthwith comply with those provisions. <br /> Dille: Signature; /L <br /> Printed Name:" <br /> ,r <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERGE AIS UNLAWFUL,ADD SHAL�1' <br /> AN EMPLOYER TO C11JONAL PENALTir$AND CIVIL FINFZ UP TO CHIC HUNDRED THOUSAND DOLLARS <br /> (5100,800,1,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S PEES,ANo DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LASOR CCD(:;. <br /> A)JTSHORIZATIO FOR OTNERTHAN C-57 SIGNING PERMIT APPLICATION <br /> ofC-57 licensaa authorized repmaiiatirtive), <br /> ,I hareby Authorize(print name)__ UAJC•.1E}h)_ Agp�- <br /> m 511011 this San Juagwln County Wall Prmoit Application on my hahelf. I>Ihdorslund this auttmrtratfon is vatld for <br /> one(1)yaar and Ic flmhad to tho worK plan d:rtndon 1109 front gaga of this appucatlon. <br /> 8.2yd21 MI <br /> 12;211/2U(IPRI 08:;;G iT\IlCk sir ;:2"!i 2!Pu? <br />