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.�-z1 <br />San Joaquin County Environmental H*alth Department Unit IV Well Permit Application S loment <br />.JOB ADDRESS:23Oo EC1S ST, Tf pERhf9T SRO: <br />LICENSED CONTRACTORS DECLARATION LCD <br />I hereby affirm that I am Ilmnsed 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 effect. <br />Licenset: U3965 _ _ Expiration Date: <br />Date: 3 - I ci -op'7 Contractor Ei SGt-14 -'D I U-1 t�& <br />Signature: <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of pedury one of the fallowing declarations: (CHECK ONE) <br />by have <br />371l maintain a 00 of the LaborrCCodeeof consent , for the perfoormance of the work fmure for or which thisnperrmit is as for <br />_✓I have and will maintain workers' compensation insurance, ss required by. Sech6n 3700 of the Labor Code, <br />for the performance cf the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are- <br />CarrierS- l _>7 -f t_ Lam— Policy Number: <br />I 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 as to become subject to the workers- compensation laws of California, and agree that if 1 <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Dater Q 7 Signature:��— <br />PrinW Nana: ✓ �V L �S �JL1 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION CovrmRAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER To CRIMINAL pENALTMS AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />P, IN DIN ION 4706 OF TOE LABOR ON COMPCOVEENSATION, <br />INTEREST, ATTORNEyle FEES, AND DAINAGES XS <br />ROVIDEDOR <br />AUT14OR``IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I L41J C �U-� (slgnaWee �47licensed authorized reprvaentative►, <br />/ /dJ n — en /- / / <br />hereby s:lthorize (print <br />to sign trtls San Joaquin County Well Permit Application on my <br />I understand this autlhodration Is valid for <br />o" (7) year and 16 Ilmited to the Work plan dated on the front page of this application, <br />88D29 -021W <br />6f2 J04 <br />£d Wd62:10 40OZ 6T --lS'W 2886 8£8 602 : *ON SNDHd SISA1Eud 0";;z punojo : WONJ <br />