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r , <br /> fBan Joaquin Cauruy.t,.nvlronmental Health iWrvIces,Unit IV W*U P67iinR-Applioation Supplement <br /> I JOB ADDRESS: Z 3 z 1Ji k w 4 9 A C;h o --' PERMtT 5iR#; <br /> LICENSED CONTRACTORS DECLARATION <br /> 'hereby affirm that i arra licensed under the provisions of Chepter 9(oommeracing with Section 7000)OF Dtwsion <br /> 3 of the Business and PtOPassions Code and my Dense is 1n full force and effect. <br /> License#: r749 6A <br /> Expiration Date: V O CaC7 <br /> Dat, ; I I 9 v — <br /> Signature' Title: <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one Of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a Certi€icate of consent to self-insure for workers'oompensation as <br /> • I <br /> Section 3700 of the labor Code, for the performance of the work for which this permit is issuevided for by <br /> d. <br /> f have and will maintain workera'compensation insurance, as required by Section 3 700 or the Labor Cod <br /> for the performance of the work fbr which this Permit is issued. My workers'compensation Insurance e, <br /> carrier and Policy numbers are: <br /> i <br /> Carrier Policy Number. � <br /> �-I certify that in tate performance of the work for which this permit is issued, i shall not err, <br /> any manner so as to become subject in Subject to the workers'oompenaaGOn laws of California and agree that if 1 <br /> t#ject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date; Signature: <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS,COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT � <br /> AN EMPLOYER To CMIMNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS i <br /> ($100,000.), IN ADD177ON TO THE COST OF COMPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 01=THE LASOR CODE. <br /> 1,42$ <br /> f <br /> (C,37 licensed authorized repr9senMtive), hereby <br /> authorize <br /> to sign this Sara Joaquin County Well Pamait Application an my behalf. I undeMand this suthofixation ia.vsNd for <br /> ane 1 enr and is Ilatailsd to the wark plan dated on the front pfte of this application. <br />