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The Wayback Machine-https://web.archive.org/web/20160803193544/http://www.sjcehd.com:80/does/Site%20... <br /> Eb CONTRACTORS':DECLARATIO[ <br /> I herebyaffirmithat t am licenser)under the prgVW-0-fts of'Chapter 9{cammencing with:Section 70t1{I}of <br /> Division-3 of the California•Businiess and Prof ssr4ris Cede and my license is.in full force and effect, x <br /> tvantracfor NameI ;� <br /> 1 license 61v Expiration Date: i L <br /> Signature. G.h 1� -•� Tine: l /�.� �N`, <br /> Print Narne, Date, I �, l_2_0 ;Z <br /> 'i. ORKERS'COM)ENSATI N DECLARATION <br /> I hereby affirm under penalty of ped4ry one of the following declarations:,{check one} <br /> I have and will maintaim.a cW ificate ofca Witt o self-insure for workers'conn pensatian as <br /> provided fory Sectian: 7(}Il;of the Lab <br /> af C©de for the performance of the work for which this <br /> permit is issued.. <br /> x. I have alio wilt maintain workers'.compensation insurance, as required by Section 3700 of the <br /> Labor^ode,for the performance of the'work for which this permit is issued_My workers <br /> corrtperisatiai7 insurance carrier and,policy numbmers are: <br /> >rar ier: 11. i/;avr2qnf� �2cof 'oCcy#: ! 7 _-/-74Exp_Date: <br /> 1 certify that in the performance of the work for which this,permit is issued; I shall not employ any persor'in <br /> any manner so as to become sutijec #Q t s�+torkers`compensation lay.,of California-and agree that if l <br /> should becorne subject to workers`compi n uon provisions,of Section 3.700 cf the Labor Ccide; I §hail` <br /> forthwith comply with those provisions. <br /> A Signature: <br /> Print{`Jit-ne: <br /> WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IWFUL, ANI] SHALL <br /> SUBJECT AN EMPLOYER,TO CRIB AAL PENALTIES AND CIVIL;,F S}�P•TO $1100,000 IN <br /> ADDITlt'SK TO THE COST OF Cf31 PL14(SkriON,:INTEREST,ATTORt+[ "S` Ea;AND DAMAGES <br /> - AS PROVIDED FOR€t1 SECTION 66,017 THE LABOR CODE <br /> AUTHORIZATION FOP,OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ► hereby authorize <br /> to sign this San Joaquin County Well&;Spring Permit Application on rny41,-p Ifr 1.vnderslartd this <br /> authorization is valid for one year and is Iimltetl b:itie work plan slated an the orif ge of this application- f <br /> EiD 2 -0I 6-23-2015A S tt:hidi aisai'lIFermat Appl kat ar, <br /> f <br />