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San Joaquin County Environmental Health Department'Jnit IJ Well PerMit Application Supplerni nt <br />J01B AbDRESS; 2 J2-0 GQ!,,'r ,�_ PERMIT— <br />-- <br />LICENSEDCONTRACTORS DECLARATION I'I_CD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing vilth Section 7000) of Div slop <br />3 of the Business and Professions Code and my license is in ,full force and elect - <br />License # �71Expiration Daae;— <br />Iante: 7 D ntra _ m —1 °,.ia4vd <br />Signature: <br />Printed Hamm: /1✓ 1A/ ,OC4 <br />WORKERS' COMPENSATION DECLARATION <br />I hemlzy afFin under pranalty Of perjury one of thefollowing ler t;Cf1G: (�; :ECe'� ONE) <br />I hnve and \A611 maintain a c;ertericate of consent to sv,,&-;nsure for'Nprkers' corrimnsat)on, as prcvided f;r <br />�by Sec"icn x700 Of -the Labor Code, forthe Perfcrmanca cr the ,vork forwhich this sernit is issued, <br />I have and will maintain workers' compensmticn insL rancc, 2;s "ec.- m -d by, SEc�J�m :3700 of the Lal~or Cc de, <br />r'or the performance of the work fcrwhich this perm;, is issur=d, uiy 1,vorkam' •;; rnporsatien Insurance <br />rater and policy nurribets erg <br />IT <br />Carrier:Policy Dumber: <br />I certifij that in the performance of the work fnr which ',his permit IS issued, I shalt nct empiey any persor in <br />any ,manner so as to become subject tc the workers' aompensati0rl la+As of Callibr• iQ, and Agree thtlt if'; <br />should bscame subject to the workers' compensation provislcns of Seeien 370(�tf t Labor Cede, I st all <br />forthwith comply with those provision$, J <br />Expiration Date: Signature: .•'�� Gi�L�L�%��L:_� <br />Printed Name- <br />WARNINC: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLaW zUt-, ANO SHALL. SUBJE C•r <br />AN EMPLOyQR TO CRIMINAL PENALTIES AND CIVIL FIN15-q UP TO ONE HUNDR!^p THOUE1AND DOLLARS <br />($100,000,), IN ADD1-nQN TO THE COST OF COMPENSATION, INTEREST, A%ORNE;Y'S FE I?S, AND DAMAGES A 5 <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUT RIZA N fiER THAN C-57 SIGNING PERMIT A, PPLICATION <br />I, . <br />(niAnittlyo ofC-57 licensed ALIhnr$ed repmsentafly e), <br />herOby authorfze (print name) 1Ll S A I, f f o <br />W sign this San Joaquin County Well Permit Appllon6an ah <br />my bptt21f. l understand this authorization is valid fol, <br />Ot7Q (1) YOgr anrd• la lirnftd to the work plan dated on flip front <br />ix►ae of this application. <br />1349-421 MI <br />&P=m4 <br />