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San Joaquin County-Environmentai hearth Deparunent <br /> WELL & $ORiNG PERi!'PET APPLICATION SUPPLEMENTAL <br /> JOE ADDRESS.2222 and 2244 S. Airport Way, Stockt9n1 CA, 95202 ?Z7,11011-4 SR <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm inch 1 arri licensed unCic2r, ine prDVtstons of Cnaplar 9 iggiri'imariCIng,J. vfab Socilon 7G13U) of <br /> Division 3 of the Ca+iform2 BUSineSS ar d Professes Cade and my!iceflsa is in fu!; force and. effecf. <br /> Contract,o,r Name: V&w ur_!t _ -- - -- ----------- --- — — <br /> License of ".5i-7' ci >=xolr n Date. <br /> Signature: -- <br /> Print fvame: I� 'l ✓� Qa►:e: <br /> WORiKERS' PENSAVON DECLARAT40N <br /> i i Hereby af,k i r u!+Jer penalty of pe,ju,y of le+:"l le�ui;uw.;ny deciaratiu,�s. (CheGk idle; <br /> 1 have and v4tt S'a1 ntwr.a oea 4if4cate of=-s-srt to setf-insul'e f0, wo`ke,,s Com.,3ensati0n. as <br /> 13 orovided for by Section 3700 of itle LaDo! Cooe, for the performance of.ine work for wnllch this <br /> perm!ii is issued- <br /> i nave and wlli ma+n?a!^ worice�s' co.----ensa}.ion 2S regUtred by Sec ion 3700 of the. <br /> Labor Cooe, forthe performance o`the work for which t,h s perm;;is issued. ivy workers' <br /> co Y• nsatian in� nCe C ;ri^r an-6 po`i>ry numb=Z-I z- <br /> Carrter: -- - - - Policy : Exp. Date: / <br /> I certify that)he performance of the work for which this permit is issued. i shah not employ any person in <br /> any manner cC as 14 bc•comc; SLt)Lii'D Tnc'Yyv'::GiS- L.Drr per -'i-TI '-w c7. %�',iurnla, and zgrce;f,at <br /> S lOUta GBCt}7@ SUGjcC }O`.`x'Ce.'j 0-- Pe <br /> rmVs o .5 S; .Ctrl^� 37,-,J- OT-V--ie Buie La rG' O c, t S:tc:; <br /> fngt4�+,rt;t4� „r y. ir+"•k'.y`f4Z �. yS`.CX':S. <br /> Siy�nature: _ <br /> PrA Name: V 1L_ ------ — - - <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE FS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO MItiAL P-ENALTIES ARID CML FINES UP TO S100,003, IN <br /> ADDiTION TO THE COST OF CCAIPETISATIO!S, l!-,TFPEST, .:r7ORNEY-S FEES, AEE 01 ANIRAGES <br /> AS PROVIDED FOR It1'SECTIO44 3706 OF THE LABOR CODE <br /> GT ORtZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> .o sign this San Jaaquia,Zo Tet!8 8 ra agP !r�:;i A;.p::.at-r41� , rzg halls. I understand Ms <br /> authorization is vain for on ye and 'y Ismi W the wog p! ,A ate chi u-1 iro nt page.ol•Ulis appiicalhoa. <br /> EHD29-016-23-2015 StieUlValxxtWell PefautAppui alfui <br />