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1,'it I @ 1f.4 0 <br />��n aoa�act��un¢r ;�.,ylrras: essxi Heaith ZerAit I�/e¢r'srrrti;c1lca;jor. 3�sa�pserrre. <br />JOE tADCFZBI.SS: CCS„J <br />`Jl V L'�l ✓ �f� <br />' C474 T R. ` aORS D IC�:J :A” j 'y sam <br />I hereby 34ffrm '° .hat i em ii=r's'- under tht Pmviaicna of "' aotar 9 (C -r- MMIC -'ng coin� -Ze Jcn 7x -G) of Civisicr; <br />of le 6tsiness and Proinssions Coda anc my ;lcanse is 'irl foil form and aem& <br />License * <br />Bails. l/ i Contras cr. <br />3ignaturs: <br />Printed name. <br />Expiration Dene: <br />i' • <br />WORKERS'COMPENSATION DECLARATION <br />1 hereby affirm under penalty of perjury one of the fbilowing 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 Labor Code, for the performance of the work for which this permit Is issued_ <br />V t have and will maintain workers' compensation Insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />terrier and policy numbers are: <br />Carrier: Policy Number: <br />I certify that in the performance of the work for which this permit is issued, I >sttell not employ any person in <br />any manner so as to become subjeat to the workers' compensation laws of California, and agree that if I <br />should become subject to the workers' campensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply/ with those pravisions- <br />Date: t. D 1 /3 _ Signature: <br />Printed Name:1A lrl�- <br />WARMNG: FAILURE TO SECURE WORKERS' COMPENSATION rl-r-RAt3E t3 UNLAWFUL, AND SHALL SUBJECT <br />AN RAPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE KUNDRE.D THOUSAND DOLLARS <br />(Si OO,OW.), IN ADDITION TO THE COST OF COMPENSATION. INTE ;LEST, ATTORNEY'S Fes, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br />(C-57 licensed sutharEred ropreeentadave), hereby <br />S Qd ria',iced i7,00F� 0k-O-)-in-U�o <br />:a sign thin San .Joaquin County Well Permit Application an my b*haif. I understand this authorization is valid for <br />2ne (1) year and is limited to the work pian. slated on the front page of this application. <br />1-17-2000 1 MI <br />IYII�ww��rOl,IrrtlgiMtla� - : •. •. <br />