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Zan Joaquin Oo unitj Environmentai Health 5erflces, Unit IV welr Farnit Appi3crtlon Seppitirnent <br />JOB ADDRESS: , Ql PERMIT SR#: <br />LICENSED CONTRACTORS DELL RATIONL{ C -I0 j <br />I hereby affirm lhat I am licensed under the provisions of Chanter 9 (commencing with Section 7000) of Division <br />3 of the Business and ��Prrafesslon/s Code and my license is in full force and eeffec)t. <br />Liceme #: Cly `f % Expiration Date: / Q /;/ / D�� <br />Date:c�/;,1 j_ (_)1Contractor. <br />Signature: <br />Title: <br />Printed name., <br />� leo a- /d&2] v <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of pejury 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 />Sgetton 3700 of the Labor Code, for the performance of the work for which this permit Is issued. <br />�f I/have and will maintain workers' compensetlon insurance, as required by Section 3700 of the Labor Cade, <br />for tete performance of the work for which this permit is Issued. My workers' compensation insurance <br />carrier and policy numbers me: <br />p L <br />Gamer. � � (Q�Pollcy Number: <br />I certify that In the performance of the work for which this permit is issued. I shalt 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 but ad to the workers' compensation provisions of Section 3700 of the Labor Code, I snail <br />forthwith comply with those provisions. <br />Date: Signature. <br />Printed Name, wQ' l� P "i <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDI-nON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />licensed authoriz�edd` ropreaentative), hereby <br />to sign this Sen Joaquin County Well PAnmit Application an my behalf. I understand this authorization Is valid for <br />one (1) year and Is limited to the work plan, darted on the front page of this application. <br />5-1 <br />