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09.07 �eU'J4bUJ4.3.1 FIFTH t-Lt7UN <br /> I <br /> Ban Joaquin County Environmental Health Department Unit IV Well Permit Application Uupplemei <br /> JOE ADDRESS: PERMIT SRS: f�15'611 <br /> LICENSED CONTRACTORSDECLARATION �L <br /> 1 hereby aMrm that i acct licensed under the provisions of Chapter 9(commencing ith Sertion 7000)of Division <br /> 3 of the Business and Profe ions Gude and my licenseIs in full for and effect <br /> Lr nae Jf: Expiration Date: 1 � ' <br /> Date: <br /> _ } Ccs ctor: <br /> Signature: Title. <br /> Printed name- <br /> WORK RS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the fellowIng declarations: ( HE i ONE) <br /> 1 hay a and will maintain a certificate of consent to sell-insure for workerscompensabon,as provided for <br /> by Section 3700 of the Labor Code.for the performance of the wom for which this permit is Issued. <br /> 1 have and will maintain workers'Damponsation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued° My workerscomponsation insurance <br /> crier and policy n bers are: <br /> Carrier: 1 I Policy Number. -- <br /> 1 certify that in the performance of the work for which this permit is issued,1 shall not employ any person In <br /> any manner so as to come subject to the r rs` mpensation laws of Calif rr0.arxi a0r that if i <br /> should become subject to the workers'compensation provisions of Seco $700 of the Labor Code,1 scrag <br /> forthwith comply with those provisions. <br /> Expiration Date: O . Signature: <br /> Printed Name: <br /> WARNING:FAILURE To SECURE WORKERS'COMPENSATION COVE CStsUNLAWFLpANUSHALLSU0JEcT <br /> AN EMPLOYER TO CRIMINAL PENALTIES D CIVIL EINES tip TO ONE HUNDRED THOUSAND DOLLARS <br /> 1 (Si 00, <br /> liD ION T E E <br /> H CO T OF COMPENSATION,INTEREST,A S FEES,AND DAMAGES AS <br /> PROVIDED <br /> AUTHORIZATION FOR QTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> t, err <br /> (signature fC- 7 licensed authorized representative), <br /> e), <br /> hereby authoriza(print mute) <br /> to signs this Sara�toaquin County Wall pe it Application on tray behalf. understand this authorization(s valid frac <br /> one('t)year and Is limited to Lite work purr dated on the front page of ttrl's apPticntiOrsa <br /> It-2�p02 J Mt <br /> I)29-02-003 <br /> 41� <br /> j . <br />'I <br />',a <br />