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San joaquir ::csunty Envi eohhiefital'Keafth DepaAnnent Unit IV Weli Permit ApplicazirsrF slip 61)t M <br />jOB ADDRESS. ... PERMIT SR 4 <br />Ll(,�,ENSED C01'flrR.,Ar._',1T0RS DECLARATION i`1..1C_d'.-1L)J1 <br />.1 hereby aftirm that. I am licensed under'.1tie provisjorm of Chapter` 9 (carr moncing With Sedion :'7.000).o€ <br />Division 3 of'the-BoOness and ProfeWons- Code and myfieense: is, in f.uJIfierce and Effect. <br />.License #: :Exkp Date: <br />-7 IZI C.ontractor:. ewem b�.i It I'M. .q Tels�h <br />Signature: --- _ _OQP�0 <br />dj &Y1.9 W4/7qq��_ <br />Print Name: <br />COMIPENSATION DECLARATiOIN <br />I hbmby'affirrn under penalty of.pequry oneof th6 following declaratiohs­#hG6k one.) <br />I have and wi'ltibalh-taih'a d6rtiftate of consent to self�insure for wort ers'tdmpensation-,':as <br />provided forbysection 3700 of the labor' Code,. fdr:the p.poormance-of the wprk for which . this <br />permit is. issued, <br />[:have andv <br />if! -maintain workers"' dompensafiorf -insurance, as required by Section: 3700 ofthe <br />Labor Code, for the -performance of t.he work: for .which this permit Is issued: M . y. workars.' <br />;compensdtibb insurance carrier and:0011dy hdr6b6m are.- <br />-74 <br />Carrier:;��:�L4L„�.� � Policy !�u€rrlyer: ��f <br />I certify that in the:perfor work fo Which this permit is issued,.,! shall not employ any <br />. . m. - <br />..anceof.ther <br />person in any manner so' as.to:,bacom'e subject to the workers4,cornponsafion 13w of California, :anti <br />agree that if :i m <br />shOUId'beco0 suNpot to workers' corrippp --provisions. . 6f.Se0tion.3700 of:t -he <br />Labor Code, I shall fdrthwith comply with those -provisions.. <br />Exp,. Date slqnaturw <br />Print Nam &4 <br />WARKING:..FAILURE.T.0-S,E:C.URE'WORKERS' COMPEr4SATtO . N CbVORXLE IS UNLAWFUL,MPLOYEWTO <br />AND SHALL SUBJECT AN-E <br />CRIMINALLPENALTIES:AND. CIVIL FWtg UP*764106,:060, SEI -AbDITION t6.tt4:Cdt.T-'OF.CO.MP.ENSAT-ION, INTEREST,.. <br />'ATTORNEY'S FEES, AND DAM.AGES:.AS PROVIDED FOR IN:SE"O.N 3706:QF TI IE. �QR COIDE <br />57 SIGN G P <br />N. <br />I rERMIT APPLICATION <br />i`ION FOR OTHER THAN -C- : <br />df C 57. licensed �a uthorize.c.1 esprese ative).: t' <br />ature. n <br />(Sig"n <br />V <br />hereby -aut"e.Wirit.name) <br />sign this San.10aquin county'W611 Perri* Aoplfcati6ii on miy behalf. I Undeiisitand thfs authorization. is. valid <br />for one year'.;andis lim'ItedlothoWdrk plati dated..db-the -frbnt--0Age of this a0plication. <br />R1291021MI <br />END 29-01 -1 M7 5 �p.G/�h/7 � ?f3iAd�F��?r <br />