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. � I <br />San .Ioaquin County Environmental Health SarViCOS. Unit IV Well Permit Application Supplement <br />PERMIT SRS: 0�� OD <br />JOB ADDRESS: <br />LICENSED CONTRACTORS DECLARATION LCD <br />I herebyaffirm that I am licensed under the provisions of chapter ror(commencing <br />eoa � king with Section 7000) of Division <br />full <br />3 of the Business and Professions Code and my license is <br />t. <br />Expiration Date: 3� <br />J ,. e zYl hl i <br />�z o / a Contractor; <br />Date: ��.}, 4 � t�JC <br />Title: UR --� - <br />Signature: <br />Printed name: <br />�I Y15)- i l P✓l1W e� <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations_ (CHECK ALL, THAT APPLY) <br />ficate of consent to self -insure for workers' compensation, ;as provided for by <br />I have and will maintain a certi <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />I have and wlli maintain workers' compensation insurance, as required by Section 3700 of the Labor Cade, <br />for the performance of Me work for which this permit Io issued. My workers' ovmpansa6on insurance <br />carrier and policy numbers are: _ <br />e� Policy Number. <br />Carrier: <br />/77,n,- IC pay -k - <br />f an arson In <br />I certify that In the performance of the work for which this permit is issued, I shall not employ y P <br />any manner so as bj ct tbecome subject the compensation provisions p'On laws of of section 3700 ofla' and the Laborree that if I <br />Code, I shall <br />should become subject to <br />forthwith comply With those provisions. <br />Date: 7 20 L . Signature: <br />Printed Name-, <br />AN EMP Cil: FAILURE TO SEt L PENALTIES AND c1VIL FINE lI UR TO ONE HUNDRED THOUSANR DOLLARON COVERAGE IS UNLAWFUL, AND S SUt�JEC7 <br />AN EMPLOYER CRIMINAL <br />(5106,400.), IN ADDITION 00 77� COST OF THEFI�ORECpt)E�r INTEREST, ATTORNEYS FEES, AND DAMAGES <br />AS <br />PROVIDED FOR IN <br />(C57 Ilcenied authorized ropresontative), heroby <br />authorizo L <br />to sign this San .Joaquin County Well Permit APPlicatlOn on my behalf. i understand this auihortzation is valid for <br />one (1) year and is limited to the worts plan.datad on the front Paye of this application. <br />S.17-20001 <br />