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ABY--10-02 11 : 34A VIiONEX, !NC . 510 568 7679 P-02 <br /> AFP-13-20027 WOCDWAP.:-- L'r'DE C01`JSUL7;iNT j:A>a <br /> r' <br /> Joaquin County Erivlronmental Health Services,Unit rV Well Permit Application Supplement <br /> JOB AUDRESS: PERMrt SRO: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> :r r' <br /> I I hereby affirm that i am kersed under the provisions of Chapter 9(cornrnenCnp with Seclion MOD)of Oivisior, l <br /> 3 of;he Business and Professions Code and my license is in full force and effect. I <br /> Lin nes Vit:fir �� Expirabw Date: �� "�• �'��C,� -- <br /> D.te. i O 03 Contrat:tor. <br /> Vgnature: :\:��',X'�C� _ Title: C� " I ?t,e <br /> Printed name:__ 1 ( 2 l <br /> f � <br /> WORKERS' COMPENSATION DECLARATION <br /> hereby affirm ander penalty of penury one of the following declarations: {GHEGK ALL THAT APPLY) <br /> !i I have and will ma;ntain a certificate of consent to self-insure for workerS'compmuottin.as proviced fer by <br /> I Sec',nr 371,10 of the LSCcr Code, for the performance of the work for which this perrr:A is issued- <br /> -�ZI have-@nd will maintain workers' Comp erisation insurance,as required by Section,170th of tMe Labor Code, <br /> rnr lhs . n,the wort,:for whicf,+.hiS permit is issued. My workers'cornpens-a ion inSumd nee <br /> Policy Number: ' <br /> r <br /> I c7 r0f tMzt in the performance et the work for which this permit ii:issued: l shall net employ any person in <br /> ary rnnnntr,n a fn hernryte sub,,e- to the workers'carnpersatlon!awe o!California, a^Q agree that.f <br /> ( shou'd becorric;ubjert to the workers'compensa+.len provisions of Section 3700 of the Labor Code, I shall f <br /> ff)101­11 c0moly with those provisions. I <br /> Signature: — \� � 1._;1� _1 A.— <br /> Printed Nance: <br /> WARN?4G:FA1LURF TO 5ECVRE WORKERS'C:OINPIENSATION COVERAGE 151114LAWFUL,AND S}tALL SU9JECT <br /> AN FMDL CYEX TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED T)4OUSAWb DOLLARS <br /> :MD000.),11?A00170N ro T-HE COST OF COMPENSATION,INTEREST,ArrORNEY'S FFIES,AND DAMAGES AS <br /> ??t:,v:l•:F.)ror2 ti:`r,�r{�,N:4706 OE YNE LABOR CODE. <br /> _�. _(si9nafuro ofC•57 licensed a", orized topreseMawt), <br /> hcine byauthorize(prim,nan,o) '•��l�i t � 4'y t C y C, <br /> to sign this San Joaculh County wall Permit Application on my behalf. I understand!his authorl=tlon is vall.1 f" <br /> ` one(1)yearana is l rnitoq'to this work pian dated on the f mt page of this application,. it <br /> 5-1Tr2UDp 1 Mf <br /> c — 1 <br /> TO1AL P.©3 <br />