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lar' ... -_ .. y�. _ - ;;�. <br />fir• `.I: .�. ','SS� .� <br />a.^�"'Sr <br />,. .y« ,.�, <br />'�.r•, <br />�'�.'_': <br />'�•�u� n <br />����K4�'�S "�« <br />y ', .,':G '� <br />'•�/:f,' �-����C'7;MY`�•il '- ... .- .. <br />wb02gagg <br />� �,.; �Yfn:Y <br />JO9 5 <br />.,�•.�•, <br />(l'`'` i�l <br />_- i <br />��y ..... <br />PERMIT° 8ft-- <br />Al717RESi <br />_ -t_7ti h.. x,w ., .1 <br />� } <br />�t,+, '• <br />���^4 <br />I.t"..•h.� <br />-��. :�I:"•� ,.��! <br />....`,, <br />,:, S�'I, �•'y :. -tom „_r.�Hiy;. _1�.. <br />^!- <br />,c!: ,[2. <br />, h .�:� `y.� _.����•' <br />��.�•�:_ , � �.� <br />^'r',�. <br />��1. ..,Z�:.. ..< f-��� <br />._�� rte'-'�.',•:if .� ..�.. -.� .� <br />LICENSED CONTRACTORS DECLARATION (LM <br />I horoby affirm that I am licensed under the provision* of Chapter 9 (comrrmrencing with Section 7000 of Division <br />3 of the Butinwis and Profesalona Code) and my license is in fuW force and gffaa /� <br />uCer�iQ # J Expiration Date: I V <br />Date: _ Con n <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will rnaintalri a certific.&ie of corlseni to self -insure for workers' compensation, as Provided for py <br />��Section 3700 of the Labor Code, for the performance of the work sor which this permit is issued- <br />�/ i have and will maintain workers' componration insurance, as required by Section 37do of the tabor Code, <br />fof th*-perfermr*nce of the work for which this permit Is issued. My workers' campentatibn insuaancan <br />carrier and polity numbers are_ <br />�( `r r <br />Carrier' ' i �V � -Q � Panty Number <br />- <br />I verify that in the periortnarnca of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation In!ws of California, and agree that if I <br />should bac*me sub)ect to the workers' compensation provisions of Section 370D of the Labor Code, I shall <br />forthwith comply with those provlslona. <br />DatO: !�7-zp°° Signature: <br />Printed Name' ' s � 17- 1'� <br />' <br />WARNING! FAILURE TO SECURE WCRKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($0 Dt FOR .) INSECTION O HE COST <br />OrT oSr COMPENSATION, OR INTEREST, ATTOttNEY'S FEF -8, AND DAMAGES AS <br />10 <br />o <br />cr ,�,� � � (C•7 license holder), hereby <br />of eqy✓. '&1Z3 _(concuhfng), W sign t,hf+s Ban <br />Joaquin County Well Dermlt Appllr.tlen en my bahsif. I undarstand thic 2uth0rization Is valid for one (1) year <br />and Is limited to the work plan dated on the Dont peg• of thin- aPpllcailon. <br />ce 39dd NoiAoo1S dJd <br />8TTTL9VG0z t 0 /V /�T <br />