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Apr .� 5-9451 p.2 <br />,��� n Jones <br />x d i !r i' + y .+r� <br />DN f 619�5,//-ZF <br />San Joaquin Coun Environmental e;k1th Servlces, unit lV Well Permit Applica�On�;P�IS+C++► <br />lg� u``o �ktop PERMIT SR#00) Q� G <br />OB ADDRESS: 'V0 of & <br />,(2G7 0% --/- 17/ 8 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />of the Business and Professions Code and my license is in full force and effect. <br />.icense #: _ 4 0 <br />5 Expiration Date: I �� <br />date: <br />l Z Q Contractor: FLS,(AA <br />Q Title: <br />Signature: <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />_ i have and will maintain a certificate of consent to self -insure for workers' compensation, 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 o Ima cetof the woerk compensation insurance, as <br />this permit isissued.required by <br />My workers'Section <br />compensat on nsura Labor <br />Code, <br />for the pert <br />carrier and policy numbers are: <br />CC <br />Policy Number <br />l� <br />Carrier: J � `(- <br />I certify that in the performance of the work for which this permit is issued, t 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 I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, i shall <br />forth' with comply with those provisions. 4 <br />Dale: � "� � Signature: <br />Printed Name:MPENSATION Inc <br />WARNING: FAILURE TO SECURE <br />(OYER O CRIMINAL PE WORKERS' <br />AND CIV FINES UP TO ONE SUBJECT <br />HUNDRED THOUSAND DOLLARS <br />AN E <br />($loo,oaPROVIDED IN ADN SECTION 3706 OF THE OF COMP <br />P CODE ON, INTEREST, ATTORNEY'S FEES, AND DAMAGES A <br />--a -Z o -A <br />licensed authorized representative), hereby <br />I <br />authorize `+�P�-`'� t <br />►— "' <br />lication on my behalf. I understand this authorization is valid for <br />to sign this San Joaquin County Well Permit App <br />one (1) year and is limited to the work plan dated on the front page of this application - <br />5 -17-20001 <br />cc"coahC07 l C _ / Q TpM7 /7T /bG <br />