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Carrier <br />A t/1 1 51 <br /> °rOl\ks - <br />sen Joaqtiln Ocunty Environmentel Heettti Depertmant Unit IV Well Permtt Application 0 upplernent <br />JOB ADDREEHIL q02.0 tay PERMIT SRO: cO303 <br />LICENSED CONTRACTORS DECLARATION (Lcr)) <br />I hereby affltrn that I am licensed under the provisions of Chapter 9 (commencing with Siogon 7000) of Divan <br />3 of the Business end Prufessions Code 110 MY licenui 16 In Mi force and ono <br />80 45/ <br />LiOanBli #: e7(7.7°C 7 - Explret1on Date: <br /> <br />E,y194,t7b 1-?;Idv-t1 <br />Date: / C Con ?wto <br />Signe-tura: --("44./ <br />Printed name: „1,4)/y <br />Titter (2,1:1 <br />WORKERS COMPENSATION DECLARATION <br />I hereby errn under penatty a perluty onS Of the following dercleretons; (CHECK ONE) <br />.4 I heVe mhd will maintain a certificate of consent o self-Ineunt for workers' coMpeneett0h, eS provided for <br />by Section 3700 of the Labor Coq., for the performance of the work for which ttlIS parmIt II issued, <br />I have end will maintain wancers' oompensetIon InsuranQe, as required by Section 3700 of the Leber Code, <br />far the performance of the work for whioh thia permit Is Issued. My winters' compensation Insuronoe <br />carrier end policy numbers sirs <br />PolicY Numlairt 7/3,- 734; <br />I cartifY that in the performance of me work for which this permit Is Issued, I shall not employ any person In <br />any manner BO as to becorri eublect to the woricarer compersetion laws of Caltfomie, and apse that if I <br />ah-ould become 5Ubled to the workers' compensetlo provleiors of Socrtion 3700 of the Leber Cade, I shall <br />forthwith comply with those Provisions <br />Dee: e" /93 Signature: ( <br />10-1— Printed Nome: tec, <br />WARNING: FAILupsr To SECURE WOOKERS' COSPENRAT1ON COVERAGE IS UNI-AWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND MIL-FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(S100,0Cfa.), IN AZ1DITtON TO THE 00810F COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES A3 <br />PROVIDED FOR IN SECTION VOA OF THE LABOR CODE, <br />AU7HORZ T1ON FOR OTHER THAN C-87 SIGNING PERMIT APPLICATION <br />yLiv (elgnoture ofS47 licensed airtharised reprreentetive), <br />hereby 4Nthorize (print name) <br />to eIgn this Gan Joequin County Well Permit piloillen on my behalf. I undaritind this atIthoritatidn is valid for <br />one (1) year and la Ilmtted to the work plan dated on the front pegs of this epplicetIon. <br />-29-02 / I