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PAGE. b[ <br /> 10/27/2603 11:12 20946834 <br /> FIFTH FLOOR . <br /> Environmental Health Department Unit N Well Permit Application Supplement <br /> San Joaquin County iPERMIT SR#: <br /> JOB ADDRESS:16 <br /> firm <br /> LICENSED CONTRACTORS DECLARATION (�_) <br /> with Section 7000)Of Division <br /> I hereby license is in full force and effect. <br /> affirm that I am licensed under the provisions of Chapter 9(commencing <br /> 3 of the Busin(e�ss and Profr� ession `od my Expiration Date: <br /> License#: ` ^ s /' / v _02/l v� <br /> /��/�7 Contractor: <br /> Date: Title: r t <br /> Signature: <br /> � v <br /> printed name: <br /> WORKERS' COMPENSATION DECLARATION(CHECK ALL THAT ADPL <br /> 1 hereby affirm under penalty of perjury one of the following declarations: n <br /> ensation,as provided for by <br /> Brent to el of the work for which this permit is issued. <br /> I have and will maintain a ceHificate of consent to self-insure for workers come <br /> Section 3700 of the Labor Code,for the p as required by section 3700 of the Labor Code, <br /> compensation insurance, workers' compensation insurance <br /> I have and will maintain workers' r whit permit is issued. My <br /> erformance of the work for which this <br /> for the p <br /> carrier and policy numbers are: 7 h �''i Q la <br /> 11 �� p policy Number: <br /> Carrier. jt Permit is issued, I shall not employ any person in <br /> _I certify that in the performance of the work for which this p shall <br /> uto become <br /> the workers'compensation provisions of Section 3700 Of the Labor Code, <br /> any manner so as to become subject to the workers'compensation laws of Californiaifia,and agree that i <br /> should becomes 1 <br /> forthwith comply with those provisions. <br /> _Signature. <br /> Date: G /� <br /> Printed Name: v <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER U CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> AN EMPLOYER <br /> OR IN SECTION I, 3706 OF THE COMPENSATION,COST OF OR INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> DITION TO THECODE- <br /> P <br /> \Q�Qy 4P (signature ofC-57 licensed authorized representatve), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> year and is limited to the work plan dated on the front page of this application. <br /> one(1)ye <br /> 1.25021 MI <br />