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A + S Y •F uy <br />al <br />San Joaquin County Environmental Health Department Unit tV Well Permit Application Supplement <br />JOB ADDRESS: -7V; S�-;l S, 6A PERMIT 9R#: I BJ q -D <br />LICENSED CONTRACTORS DECLARATIONL( CD <br />1 hereby affirm tW I am licensed under the pmviolons of Chaptar 9 (commenaing with Section y01)0) of Division <br />3 of the Business and Profeeaions CMM and my license is in full ford and effect_ <br />Licenea #. 2100 -7 expiration pate: <br />Date: /01 �- Contractor 'e!� <br />Signature: __ G Title:h - <br />Printed name; 86rh1 C r hJ ( i s }� r>.aa� c <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following ancfarAons: (CHECK SNE) <br />_ I have and will maintain a certftaw of consent to *04nsum for wadcers' cdrr;p,ensation, as providetl for <br />by Section 3700 of the Labor Gods, for the performance, of the work for which this permit Is issued. <br />I have and will maintain workers' corrgmnsation insuranCb, as required by Section 3700 of the LaWr Code, <br />for the perforrnwoe tithe work for which this permit is issued, Nly workers' Cgmpensetfon Insurance <br />carrier and policy number; are: T <br />Carrier: —" � V <br />Policy Number: c),Z. 7 <br />i cartify that in the porfarmanca of the work for which this permit b Waved, I shall not employ any person in <br />any manna ao es to become oubjeat to the wmkcrs' Compensation laws of Caiifamia, end agree thv if I <br />should become subject to the workers' compinsafion provisions of Section 5700 of ting Labor Code, I shall <br />farthwhh comply with those D provisions - <br />Expiration <br />Expiration Date: d K Signature r` L <br />C <br />Printed Name: N C, AE- too n ki4-�r, <br />WARMNOi FArLURE TO SECU>tg WORKERS' COMPENSATION COVERAGE t5 UNLAWFUL, AND SHALL SUBJECT <br />AN 1=MPLQYER TO CRIMINAL PENALT1121 ANO CML fgft-8 UP TO ME HUNDRE13 THOUSAND DOLLARS <br />($i00,000.), IN ADDITION TO THE COST OF COtiMPONSATM, INTEREST, A'FTOMEY'S FEES. AND DAMAGES AS <br />PROVIDED FOR W SECTION 3700, OF THE L.Abos t coDE. <br />AUTHOWATION FOR TWER THAN 0-57 SION.ING PERMIT APPLICATION <br />(elgnatilre oi"7 ](ganged <br />Quthorlmd rvproeantad"), <br />hereby authort o (Pant name)-5 <br />to +elan this San Joaquin County Well Permit Application on my behalf. I understand this authohimflon Is valid for <br />ani (t) year and is Ilml od to tho work plan doftd on the front pace of this ippticstion. <br />EHD 2¢02-W I <br />NSM <br />60/Z0 39bd AT-Itl7 rnN qn 1 vA i q maraca i nnrr �n , <br />