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a <br /> lion Joaquin County gnvironmental Health Department Unit IV Well Nrmft Application aupplemant <br /> JOB ADDRil1111lla11:_ ;; L900 SrIM-4 0H ISD a j PERMIT SR#- <br /> LICENSED CONTRACTORS DECLARATfON <br /> I hereby affirm that I am Iloaneed under the prwsions of Chapter 0 (commencing with $110tPn 7000)of Division <br /> 3 of the Business rind Prolassions Cade and my'llcense IE In full forme and ofto. <br /> Llcanaa 0: - - T '7t J '7 __ lExplratton Data:. <br /> Data; / a Can ecte <br /> 8fgnartttra: Tltte;__--�.i�iafi�/�. . <br /> Printled nouns; "- I) <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby afirm under penal y of penury one.of the following decloretlana; (CHECK ONIE) <br /> I have and will maintain a cer1ftale of consent 0 self-Insure:for wnrkars':compensatlan. as provided for <br /> by Section 3700 of the LabPr Cotte, far the performance of the wont for whlah this permit is latsuad, <br /> haw and will maintain wor Care' oompensatlon 4nsuranrm, as raqulred ay Sectlon 3700 pt the tabor Code, <br /> for the p0brmance of ft work Nr which this permit is isauad. My woruers' oornpansaticn Insurance <br /> carrier and pcallcy numbers are <br /> Carrlsr r Policy Numtor: -11 7;56 S <br /> I cartlfy that in the performance of the work for wh;oh this perrnit is Issued, 100 not employ Any person In <br /> any manner so as to becomat oubJect to the woriCaro' compenentlan IAws Of California, and agree that If 1 <br /> shoLAd beoofne subject to the wo*ora'campehsetla prav*cmll of Section 3700 of the Labor Coda, l it <br /> forthwith compty with those provisions. <br /> r f. <br /> Data, 1f SISnatura' <br /> tiXp 10 /p� � Printed Name' � <br /> WARNING! FAII.URK TO SIOu114e WORKERS'COMPEhi8AT1ON COVEWE to URI-AWFUL.ANCI 13HALl_SUBJECT� <br /> AN EMPLOYER TO CRIMINAL PENALTteB ANG ONIL FIN95 UP TO ONE MUNDARD THOUSAND DOiLt.Atga <br /> M1011,11M.), IN ADDITION TO THS CQBI OF COMPENIATION, INTEREST,(ATTORNEY'S F1568,ANP oAMA498 AS <br /> 01tOV10913 FOR IN SECTION 3701 OF THE LABOR COOS, <br /> ACJ R TION POR.O�THAN C•67 SIGNING PERMIT APp�,ICATION <br /> r <br /> iUfpmratCrre afC-Q'f tiaansad+��orla;est nprwantadw►}, <br /> hereby epthaalte(print ngrnq) — <br /> to slam We Ran JaagwEn County Well Psrmtt plia»tlen an my behalf. I undeptand this authorlsation In valid for <br /> one 11)year and Is limited to the warit plana dated an the front page ofthla ttppycwgcn. s <br /> Lj,"-02!Ml <br /> . I <br /> k <br />