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San Joaquin County Ernironrnenlal Health Deparlrnvnt Unit IV Well Permit Application Supplement <br />JpBADQRES$:L`j] � 1 �osiLL Sh-e4 PERMIT SRO: <br />1L^ 9,4" O6 <br />LICENSED CONTRACTORS DECLARATION tj M <br />! hemby affirm that I am licensed under the provisions of Chapter 9 (commencing with $Mellon 7000) of Divisior <br />3 of the Businass and Professions Cods and my ilcense is in fall force and effect I <br />License# �` "� j l in Uplratlon Date: - 3 — o `�t <br />Date: ntrector, <br />Signature: Title (� <br />Printed narffe' <br />WORKERS' COMPENSATION DECLARATION <br />I tfereby 8" under penalty of pel ury One of the following declarations (CHECK ONE) <br />I have and will maintain a certificate of consent to adfansure for wo1k9r3' cornpensetion, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which thio permit Is issued. <br />I have and will maintain workers' compensation k=rance, es required by Section 3700 of the Labor Code, <br />for the performance of the work for which Ihis perrnd is issued. My workers' compensation el"ance <br />carrter and policy numbers ars: ry (-Policy <br />Carrlsr: KL Is 1� }iarNumter. <br />I certify that in the performance of the worts for which This permit Is Issued, I shall not employ any person In <br />any manner so es to become subject to the workefe' compensation laws of California, and agree thal if I <br />V,culd become subject to the wooers' compensation proves a Sect 3-700 of the Labor Code, I shall <br />forthwith comply with those proviaiona. <br />Date: Signature: <br />PrintedNsme: <br />WARNING- FAll uft TO SECURE WORMRB' COMPENSATION COVMGE IS UNLAWFUL, AND $HALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CMI. FINES UP TO ONE HUNDRED THOU"No DOLLAR$ <br />(1111 00.000.), IN ADDITION TO THE 009T OF COMPENSATION, INTEREST, ATTOFtNEY'ti FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3708 Of THE LABOR CODE. <br />N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />',(signature oIC-57 licensed authorized representative), <br />hereby authorize (Prf narrm) C� C`I S h/1 I tr <br />t0411001 this San 10"Win County Well Permit AppllcaVan on my Aahstf, I unck0 anp this authorization is vai10 for <br />ons (1) year and Is 10"A d to the work pian dated on the front page of this oppllcstivn. <br />8-29..02, Mi <br />