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�J 002 <br /> San Joaquin county (✓nvironmental Health Seeg, IV Well P@rmitrApplicatian Suprplement <br /> C�t,a PERP 1T' SR#:- <br /> .10B ADDRESS: f1 . <br /> ' T-J <br /> LICENSED CONTRACTORS DECLARATION (LCIS) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect_ <br /> License#: . / 0/6 Expiration Date; .� <br /> Date: ontractor ]�{�lAr -Inc <br /> $lgnature Title: — <br /> Printed name: WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of tho 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 /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> I leave and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier anndd�policy numbers are: s� <br /> Carrier_�1LC� 1 AII-k/- _Policy Number; � „ -•_1_✓_ T�� - <br /> I 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 become subject to the workers'compensation laws of California, and agree that it I <br /> should become subject to the workers'compensation Provisions of Styation 3700 of the Labor Code. I shall <br /> forthwit comf ly with those provisions. , <br /> Date' Si4PY � I'`'{ <br /> _.— <br /> Printed Name: -�- <br /> _� a-'��9— YL' <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN>rMPLOYER TO cRIMINAL PENALTIES AND CIVIC_FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED N ADN SECTION 37 6 OF T OF COM R GpATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> (C--,5r7�license ho0zedrcpresentativo), hereby <br /> / <br /> authorize - <br /> to sign this San Jo in County Well permit Appiic ion on my behalf. I undetstand this authorization Is valid fog' <br /> one Gear and is limite0 to the work plan dated on the front pagn of this appricatioon- <br /> WCJ�I� Wd vs,0 L F�R(Z I_V01 0 1 <br />