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San Joaquin County E:nvironmontal HOAM Gervices, Unit IV WIN Parma Application Supplement <br />JOB ADDRESS: 2k fCk =-y (-�t� �UPE IMIT SRS: <br />UCENSED CONTRACTORS DECLARATION (Lrep <br />1 hereby affirm that I am iicsnaed under the provisions Of Chapter 9 (commencing with Seotlon 7000) of Division <br />3 of the Business and Profossions Code and my license It in full force and effect. <br />License fl: 7 ,c2 sl n Expiration Date: V <br />Date, �, (y, Contr tor: <br />Slgnatur*- Title-, <br />PrinUW name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby attirm wider penalty of perjury one of the following deciaratkms: (CHECK ALL THAT APPLY) <br />,.� I hairs and will malntaln a Certfficste of consent to sell -insure for workers' oampenantlon, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />I have and will maintain workara' compena*W insurance, as required by Section 37b0 of the labor Code, <br />for the performance of the work for wh)ch this permit is issued. My workers' compensation insurance <br />carrier and policy numbers re: ( 1 <br />Carrier: , � ,y 1.��1 Polley Number: <br />I cartly that in ft performance of the work for which this permit Is issued, I shall not employ any person in <br />any marner so as to baddme subject to the workers' oorttpensation Is" of California, and agree Chet It I <br />should b000me subject to the worKers' compenaadon prov 8 on 3700 of the Labor Code, I shall <br />fortftwith comply witht thoso provisions. <br />,pate. �I <br />o Signatuwt <br />�T Prfnted Nome; <br />WARNING: IFAlLUAR TO SECURE WORKeRVOMPCNs"ON COV"AGE IS UNLAWFUL, AND SHALL SUBJECT" <br />AN EMPLOYEE TO CF1IWMAL PENALTIES AND CML FINE$ UP TO ONE HUNDRRD THOUSAND DOU A>RS <br />1 D SAN Ttdji THE COST O 0e�!! �� t, WR" -ST. ATTORNEWS FEES, AND DANAOES AS <br />PROYM <br />ofC47 iioensed authorised mpremmta*mv <br />hwebysuttortis(pMnlfunN) bjtre¢fc L e7r <br />to sign this SM Joaquin County Well Permit Applloatlan on my behalf. I undaratand tMa authorl:atron Is valid for <br />MW (1) year and Is Vnikad to the work plan dated on the [rent papa of thb ePplioaftrL <br />EO/EO 39VJ <br />a093S <br />SNI JNI77IaG AGV3SV3 <br />OEo0i969% 04:60 o00?i9Z/CG <br />TT958E9916i Eb:01 VBBZ/9Z/EB <br />