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,u. ��ivoa000la rl I erW-XJ ex�.e•x i i rt <br /> 04JB5/2080 16:10 2e946'i' 't AGE ST"TON PAGE 01/81 <br /> "JOB ADDRESS: `- ±PERMI`�`-' <br /> C}z:�_•.- ...__ :�9�_;d �'F;.��—�v� j.: � �._��..,.., �_ ,�e.r4�s�._ R�.��:5..._.., f L��'`�i� _..A ,1 L'G: . <br /> LICENSED CONTRACTORS DECLARATION ( CEJ <br /> I hereby at'firrn that I am licensed under the provisions cad Chapter 9(=nmendng with Section 7000 of Divislort <br /> 3 of the Business and Profession Code)and my IiGanse is in full force and effect <br /> License# 5�c; Expiration Data J& t , Z P v 1 <br /> Date:_ �, 7 G G� Contract r. <br /> signature: Title- <br /> Printe na rcffirxo <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penally of perjury one of the following deciaralione, (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certficite of contiont to selflnisure for walkers'c mpensalian, as provided for by <br /> Section 3700 of the Labor Code,for the perforrrance of the work for which this permit is Issued. <br /> ✓ I have and will maintain workers'compeneabon in&vrance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for whlCh this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: -1 1N5• Policy Number. V16 <br /> Z I certify that In the performance of the work for which this permit Is Issued, I shall not employ any person In <br /> any manner so as to became subject to tho workeres' compensatlan laws of California, and agree that H 1 <br /> should become subject to the workers' compensation provisrans of Sectlon 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. � l <br /> Date:�� -t'f-? Signature: L <br /> Printed Name: ,C,F'f"� �' y <br /> WARMNG: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES up To ONE HUNDRED THOUSAND DOi LARS <br /> IN ADDITION TO THE COST OF COMPENSATTg TEREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> PR41Mf1)FOR IN SECTION 3706 OF THE LARO E. <br /> I, i IC-87 licanne holder),hereby <br /> + <br /> authorize a �' Qi o 1sultiA9),to sign thI%San <br /> i^� � � ✓� of C� C . <br /> Joaquin County Well Permit Applltalion an my behalf. I understand this authorization is vefld for one(9)yepr <br /> and is limped to the work plan listed on tho front page of thin application, <br /> } <br /> 1 <br />