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Ban Joaquin County Environmental Health nice% Unit IV Well Permit Application Supplement <br />JOB ADDRESS; Afige ( CA) asr <br />LICENSED CONTRACTORS DECLARATION (LC) <br />I hereby affirm that I am licensed under the provisIons of Chapter 9 (col-romancing with Section 7000) of Division <br />3 or theo BUslness end Prefesaiorts Code and my Oconee tsa In full force and effect. <br />License 0: ?-45:1 6 c6,13 Expiration Doze: 5—/3/ /03 <br />Date: SI 3 07— <br />il <br />Printed name'. /4/05C1ZrC- _1 rz PflefiC <br />WORKERS COMPENSATION DECLARATION <br />I nereby affirm under penalty oF perjury one of the folleWing declarations: (CHECK ALL THAT APPLY) <br />) ne;fai and will maintain a certificate of convent to self-insure for workers' compensation, as provided for by <br />Section 3T00 of' the Labor Code, for the performance of the work for which this perrnit it issued, <br />have and will Mnintain workaii' compensation in ice, Al required ay, Section 3700 of the Labor Coda, <br />for the performance of the work for which thin permit lc Issued_ My workers' compensation irisWilinee <br />carrier and policy numbers ere: <br />Carrier: Policy Number: (‘:ts 6 6 3 <br />PERMIT SR*: <br />Signature: <br />cprirr=tor: , —re& - irupre_-ritte,"„ <br />f <br />Title; Parf c-Ydir.0"c <br />[5/U/L.1'2 FI41 15:03 FAX 018 j,zgoo MRS <br />05/0a/2802 13:139 294634aR. FIFTH Ft.,00R <br />I cartry that in the performance of the work for whIch this permit is issued, I shall not employ any person In <br />any MerWler im Isola bilielorne subject to the workers' corn pensation laws of California. and IlDrise that if I <br />shoUld become subJect tcb the werkons' compensation provisione Of SeCtIon 3700 of the Labor Code, I shalll <br />forthwith corriply, with *Iota provisions <br />Alese-sK ,IcizespAK <br />WARNINC: FAILURE TO SECURE WO R5 COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN ENFLOTENTo'CRIMINAL rehLALTiES AND .crifIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(610,000), IN ADOlT10114 TOME COST OF COMPENSATIOPJ, INTEREST, ATTORNEY'S FEES, AND DANJA0Es <br />PROVIDED FOR IN SECTION 37116 OF THE LABOR CODE- <br />hereby authorize for rit mune) f OR niz i-Jortar7baL/ (-7: • _K ---1\'‘? <br />to sign RAJA San Joaquin County Woll Permit Application on my behalf. i understand this authorisation is inilid ter <br />ens (1) year end 1st limited to the wore plan dated on the front poor of this application. <br />54 T4000104 <br />Dote; <br /> 511 0 t— Signature: <br />Printed Name; <br />(signature 0=47 lloarided authorised reprasientative).