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Bain Joaquin County Environtnenul Health Solvices,unit IV Well PerMft Application Supplement <br /> JOB AVnRESS; PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LGA]) <br /> herahy affirm that I am licensed under the provisions of.:Chaptor 9 (commencing with Section 7000) if Division <br /> 3 cit the Business and profession-g.Corte and my licanse la In full force and effect. <br /> License 0- 57 EViration Date:_ ,_oy-V-d.3 <br /> Dstis: 6V-4,Z-61 Contractor, <br /> Slgnature; _�._..��Tltl�raF.�L�. �I�,.a.rn cJr�_ <br /> Printed name: •'f►isO drWtll/t' <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under'penalty of perjury one of the Following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for warkers'componsatlon,as provided for by <br /> Saoflan 3700 of the Labor Lode, for the perform Rnrn of the work for which this permit is i"ued. <br /> _Znave and will maintain workers'compensation insurance,as required by Section 0700 of the Labor Code, <br /> for the performance;of the work for which this permit is hisued. My workers'camgansaClari insurance <br /> carrier and policy numbers are: <br /> policy Numbor: ✓y'�L�✓� `3�l/t.5"o Z �0-0 <br /> _I certify that in the performance of the work for which this parrnh is issued, I shall nol aettpluy wy person in <br /> any manner so as to became sublact to the workers'cornpensetlon lawR of California, wd agree that It I <br /> should become sobjer:i to thew workers'compen4ation provisions of Section 3700 of the Labor Code, I shRil <br /> forthwith comply with those provisions. <br /> Oate: o ii/-OZ"0 I - - ,Slgnaturer, <br /> Printed Name:,_ car-.'►to <br /> WARNING:FAILURE TO SECURE:WORKERS'CoMpL-NSATION COVERAGE IS UNLAWFUL,,ANO SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (SjgQ,tltltl.l,IN Alin ITiON'TO THE COST OF COMPENSATION.INTF-REST,ATTORNEY'S FFFS,AND RAmAGES AS <br /> PROMF-A FOR IN SECTION 3706 OF THE L.AF3OR CODE. <br /> sconeed muthaftx!representative),h0mby <br /> autherixe 1�C- Lt �'TLCL� �Ao <br /> �i1�^c +aca" j -� <br /> to sion this Sae Joaquin County woil Pomlit Application an mY behalf i undumt0nd thle autharbatt n is valid for <br /> one(1)year and is Itmlted to the work plan dated on the front Pana of this appilcatlon. <br /> SAT-2000t MI ____ <br />