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�.. / 1-2, -..� <br /> A <br /> San Joaquin County Environmental Health Department Unit IV wail Permit AP tirstttiijon SSupptamantal <br /> JOB ADDRESS: �gZ- 1-1 . ^WLi*0'1 PERMIT 5R# o���/ 1 <br /> LICENSE CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 0(cornmen^ing with Section i 00o)of <br /> Division 3 of the Business alta Professions Code and my license is in full forCe and e <br /> License#: 1 0 9 01 Ex Date: I D <br /> Date: ,0 Contractor: \/A,0 Vt L 1 <br /> Signeture: f Title: (� <br /> Print 1'iamc: �/ l C, ( <br /> WORKER'S COMPENSA Q <br /> N DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> l have and will maintain a certificate of consent to selfLinsure for workers'compensation,as <br /> provided for by section -3700 of the labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the I <br /> Labor Cade,for the performance of the work for which this permit Is Issued. My workers' <br /> ! compensation insurance carriel,and policy numbers are: j� t <br /> i Carrier:N4e <br /> P <br /> olicy Number: <br /> I certify that In the performance of the work for which this permit Is issued, I shall not employ any i <br /> person in any manner so as to become subject to the workers'compensation law of California,and <br /> agree that if I should become subject to workers'compensation provislons of Section 3700 of the <br /> Labor Code, I shall forthwith Comply with those previa` ns. <br /> r <br /> Exp, Date: <br /> Signature- <br /> Print Name: �C� Ej2� C ve <br /> WARNING:FAILURE TO SECURE WORKERS`COMPENSATION COVERAGE IS UNLAWFUL,AND 514ALL 8UBJECT AN MPLAYER TO <br /> CMf"AL PENALTIES AND CIVIL FINES up To$100,000,IN ADDITION TO THE coST OF CDMpEN8ATt0 }INTEREST, <br /> ATTORMtaN'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTIOH 3706 OF THE LABOR CODE. <br /> O I R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i' (signature of C-57 licensed authorized e+epnesentetive), <br /> hereby authorize(print nams) <br /> to <br /> sign this Son Joaquin county Well Paa'mit Application on my lahaff. 1 undereUnd this authorization Is valid <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> 8lZi102411 <br /> END2"1 11JUaT <br /> W-'U FZRMr APP <br /> , <br /> TO 3Did ENI-nI6a M?A 80966SC60Z V0:EO 800Z/6Z/t0 <br />