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Sari immuln County OnvirMmental Health Services Unit IV Well Permit. Application Supplernent <br />.JOB ADDRESS: Z��Rmllr SRO: <br />LICENSED CONTRACTORS DECLARATION (=) <br />I hereby affirm that I am licensed under the provisions of Chapter G (commencing with Section 7000) of Division <br />3 Of the Business and Professions Code and my license is In full force and effect <br />Licensee: _12Q2QA Expiration Date: CXR <br />OVA'. oniractor. t <br />_ Title: Al <br />IV Prtnbd name. Jodu i _ IAn. <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the .*allowing declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a oerlikste of consent to self insure for workers' compensation. as prov[ded for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. <br />I have and will maintain workers' compensation Insurance, as required by Section 3700 of the Labor Code, <br />For the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carder: Policy Number; <br />r <br />I certify that in the performance of the work for which this permit is issued, i shalt not employ any person in <br />any manner so as to become subject to the workers' compensaton laws of California. and agree that if ! <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Data: <br />Signature: <br />P* ted Nance: <br />WARMNO: FAILURE.T,O SECURE wORX , COMPGNSATfoN CCVERAOE 18 -UNLAWFUL. AND -SHALL SUBJIC-T <br />AM EMPLOYER TO C1dtMi10L PEMLT1Et1 AND CIVIL FINES UP TO ONE HUNOItIED THOUSAND DOLLARS <br />(i71a0.iI0o.}, IN AIMITION TO TME COST OF COMPENSATIDN, INTEREST, ATTORNEY'S FEES. AND DAM*GES As <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />R IC•57lkowed authorized repnrsenrstive), hereby <br />authority <br />to shp this Sen Joaquin County Well PermH Applioadon on my bel►alf. I understand this authOrimtlan Is valid for <br />and is limited to the wort: pian dated on the front page of this <br />c- -.q <br />