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San Joaquin Cmurty Environtnentnl Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:_ WAS _rfa/ntcnP,a, PERMIT SR#: a?)&12 <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby afiinn thal I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Flusiness and Prof�ssionsCode and my license is in full force and effect. <br /> Liconss i1: Expiration Date: <br /> Date:_N1LA1,� _Contractor 1(J{1 .w -fc� (�C_,i-illjvv3(� <br /> SiOnaf.urr: �� - Title:�p.,a�.4t.T /1�(.A.✓ArEC <br /> Printed name:- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby uffirm under Penalty of perjury one of the following declaralions: (CHECK ALL THAT APPLY) <br /> _ I hwa and will maintain a certificate of convent to self-insure for workers'compensation, as provided for by <br /> —,x,clion 3700 of the L abor Cod_•for the performance or the work for which this permit is issued. <br /> K I have and will rnain,ain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the pcedormnnce of the work for which this permit is issued. My workers'compensation insurance <br /> ca«icrr and policy numbers arc:O n <br /> Cwrler:_'aa9..�<-�N n c( Policy Number:_()L4 L-(()()() <br /> , Q-0 �� <br /> g <br /> a>rVY that irI the parrornlance of the work for which this permit is issued, 1 shall not employ any person in <br /> any manner so as to become subject to the workers compensation laws of California, and agree that if I <br /> si.ronld become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Dat.;; :1 _3 Signature <br /> Printed Name: y <br /> WARNINGFAILURF TO SECURE VIIORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANDCIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> 0100,000.)•IN ADDI'r7ON TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FLOOR IN SECTION 370066 OF THE LABOR CODF. <br /> „_{siynafurn ofC-57 licensed authorized representative), <br /> hcroihy aaHroN/e Wont 4P,t. (,, d <br /> to slfln Lhis San Joaquin County Wulf Permit Application on my behalf. I understand this authorization Is valid for <br /> Dna 11)y'e ar anti is limilorl to tho work plan dated on the front page of this application. <br /> 6-1 r-7000!MI <br />