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fan ,Joaquin rcunt r E nvirorr metal Hsall:l~ ae-Acas, Unit t1/ Weir psnnit Appilcat!on 3n �•, <br />3i1117/so- th <br />aiOB�lJ�d"'ii.s�+�i:�'::il'R/ <br />i ^ereby affirm that l S -n i3=FlSad under, die prcvisicne of Chapter 9 (Ccrrtrtrenr�rg wits Section 7W0) Of Division <br />of 11e Business and Proiesslonu Ccde =d my ilcanse is In idl forca and affect <br />License '51� 1 Exotradon Deis: <br />4/LC��^�✓'/ �Q� <br />03te; ) D; �?f3trdC:Gr ' t i (�- <br />=05,5001 <br />WORKERS'COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the foiiowing declarations: (CHECK ALL. THAT APPLY) <br />I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />/Section 3700 of the tabor Cade, for the performance of the work for which this permit Is issued. <br />V I have ar�d will maintain workers' compensation insurance, as required by Section 3700 of the tabor Code, <br />for the petforrnance of the work for which this permit is issued. My workers" compensation insurance <br />carrier �and �policy numbers ,ere: <br />Carrier: Policy Number; <br />I certify that in the pe dormanee of the work for which this permit is issued, I shelf not employ any person In' <br />any manner so as to become subject to the workars' compensalion laws of California, and agree that if t <br />shauld become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I atiail <br />forthwith comply with those provisions. <br />Date:0I Signature: <br />— w <br />Printed Name: <br />WARNING: FAILUPE TO SECURE WORKERS' COMPENffiAT10N OVERAfw IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PERALTIES AND CML FINE$ UP TO Q"E KUNDRED THOUSAND t70LLARS ' <br />(51 00,000.), 1N ADDITION TO THE COST OF COMPENSATION. INTEREST, ATTORNEY'S Fes, AND DAMAGES A3 <br />PROVIDED FOR IN SECTION 3706 OF THt3 LABOR CODE, <br />e fZ— (C-57 licensed authorir-d -pr%4*ntattm), hereby <br />V)kf. <br />to sign thin San .Joaquin County Well Pernidt App lieatlon an my bshati. 1 understand this authvrix"on is voild for <br />one (1) year and is limited to the work pian, dated on the front papv of this application. <br />5-17-2= 1 MI <br />