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San Joagtairl County Enviranmental Mo'alth Department Unit IV Wit Palmar— JOB ADDRESS: PERMIT SR#' LICENSED CONTRACTORS DECLARATION CQ I hereby attlrm that I am lk:eiwad under the provisions of Choptet 9 (commencing with Sectirxr 1000) of Civinion 3 of the Husine33 and Piultsssions Cridta and my tirenso is in full tot -cc and r+lluc:t- 1 lconsea tf: SS `7197 Expiration rats: 6/-3/-61 CIHtP.:. d �' � Q CLlflttdc:l(Ir _ L 1� WORKERS' COMPENSATION MiCLARATION I hereby attrr►n under parially of perjury ono of the fullowin0 dedaration.w. (CHECK ALL. THAT' APPLY) _ I have rami will maintain a ckrtific;ate of rnnsenl to self -Insure for workers' compensation, as provided fix• by Section 3700 ut the Labor Cude, for the perforntrinrg of the work tot- which thl.s I,rl'mit is i+;sutlil. Zh;1ve and will maintain worker*'rompen*ation insufance, as requiitW by Secticirt 3700 (it the i avoir Coca+:, for the per forn rhea of Urer work for which this parmit is issued. My workers' wrnNurtsiation a►auranett Curr for and pol- y numhPrs Are: / Carrier: /??� ! '`J S ; Pullcy Number: ZIrerthat in mo rr+rlurrt once of the work for which this . Prrnil is issueu, 1 shrill not employern htsrson in rh' l n Y any manner so ac to becumu Nubject to the workers' compensation Inws of C11Ufornia, wid agrou Itint if I shrndd bt=)rno ►;rihjHct l0 the workefs' cunrpensatton provisions of Section 37M �t_Wa f bi7r Code,, I shall Jul Ulwith r:orrthly with those provisions Date: CS 8'..� �' v� Slgnatur `l r' Printad Na ai4r`=. �C c t ri+-o d%• %mac Ci�!> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE Is UNI AWFUL, ANn $HAI 1. SUBJkC•r AN FMPLOYER'I O CRIMINAL PENALTIES AND CIVIL DINES UP To ONE HUNURI.n THOUSAND 00111 -ARS (S100,0110.), IN ADO(TION TO THE COS I OF COMPFNSA'r1ON, IN 11. -REST, ATTORNLY'S FSS, AND 13AMAGE3 AS PROVIDED FOR IN SEC;'I ION 3106 OF THE LABOR GOIDE. 'j, � I GI•/.'t7r4']... _ ,.----- _...._("ynAqjreof/C•5'r lieanawd 3trthoriznd represtmtabva), howeby authorize (print nar.iu). f1 t/4- �Q7'�6-0,e- to IF to talon this Sart joaquur County Well Permit Application on my behalf. I understand thio authortxacit t3 valid for ono (1) year and Ix limited to ehn work plan dwtod on the front page of this application.