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San Joaquin County Envlranmental Health Department unt <br />JOB ADDRESS: 236 O ECl S4. Tfa <br />lV Well Permit <br />PERNgT SR#: <br />Ilcation Supplement <br />D5! i?5(p <br />LICENSED CONTRACTORS DECLARATION LGD <br />I hereby affirm that i am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and effe<1. <br />License 0: Q 3 �t�5 Expiration Date: <br />Date: <br />-14-0'7 Contractor.. F1SGt-k rDR�I.LI Alfr <br />Signatufe: <br />Printsd name: <br />I, Title: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penally of perjury one of the following declarations: (CHECK ONE) <br />I have and will maintain a Certificale of consent <br />&2ti0n, es <br />by Section 3700 of the Labor Code, for t1w perform nae of the work for n <br />which this issued.permit is sued. for <br />✓I have and will maintain workers' compensafion insurance, es required by Section 3700 of the Labor Code, <br />—" <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Policy Number. <br />Catrlen - <br />certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so a5 to become subieci to the workers' compensation laws of California, and agree that if I <br />should become subject to the workers' compenselion provisions of Section 3700 or then Labor Cade, I shall <br />forthwith eomply�with those provisions. <br />Expiration Date: C�7 - Signature: -D <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION CoVEFtAGE IS UNLAWFUL, AND SHALL SUEiJECT <br />AN EMPLOYER TQ CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(sloo,UDD.J, IN PSECT 0113706 OF THE CODEON TO THE COST OF . <br />INTEREST, ATTORNEY'$ FEES, AND DAMAGES x5 <br />ROVIDED OR <br />AUTHORyi7.ATiON FOR 01 -HER THAN C•57 SIGNING PERMIT APPLICATION <br />i �Qy V C+ FLC1l--�- (slgnatuceyo .67 licensed au� reprovenUtivej, <br />hereby authorize {pdnt name) <br />to sign this San Joaquln County Weil Permit Application on my behalf. I underatend this authorization is valid for <br />otic (m) year and IS limited to the Work plan dated on the front page of thie application. <br />SHD 29-02-10: <br />6W04 <br />£d W'd6e: TO 400E 6T £886 B£8 602 : 'ON SNOHd s SSfi I pus oaaz purtojo : W083 <br />