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V <br /> r <br /> Sari.loaquin County Envlrngmcnta(Health urvicas,limit P/Well Permit Appttc#t1Ah soppfement i <br /> i JOB ADDRESS:.... PERMrr $# : <br /> i <br /> LICENSER CONTRACTORS DECLARATION LM <br /> I hereby affirm fast)OM i1Censad under thin GtOVWOrs Of Chapter 9(cornmericing with SWIon 7000)of DiylsiGn <br /> 3 of ilia Business and Fmfessfons Coda and my ik:ense Is in full farce and of t. <br /> Lir.-Anae#:__ ��. Z f _ Expiration Date:-- -~_-,r) — <br /> Data: Contractor: �' / ' e rav- <br /> A i Tift i EN <br /> Printed name: <br /> . L;! Lr_ ; <br /> WORKFERS'COMPENSATION DECLARATION. I <br /> i <br /> { I fiareby affirm under penztlty of pedUry one of the following d"lareraons: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certiFicats of consant to self Insure for workers'dompensatiun,as grovidea for by I <br /> { Saction 3700 of the Labor Code,for the parformanca of tha vyork for which this permit is issued. <br /> -I have end will maintain workers'comoonsavon insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for wWch this pefrnit is Issued. My warkers'compensation insut, <br /> carrier and paric numbem are: nce <br /> _ Ptrtity Number: �� t �•� # <br /> I certify that in Me performance of the wont for witiich flus permit is issued, I shaft not ernpfoy any person in � <br /> any mariner so as to Became sut lect to tfle workers'Carnpen*atiarl Iaws of California,and agree that if I <br /> should become subject to die wofkers'compensation provisions of Section 3700 of the Labor Code.I shall <br /> forthwith comply with those pravistons. <br /> Bate: _Signature; <br /> Printed Nara% i <br /> WARNING:PAtLURE TO SI=CURE WOFiXERV COMPENSATION COVERAQe 19 UNLAWFUL,AND SNALL.SU6,19cr <br /> AN EMPLOYER To CRNINAL PENALTIES AND CIVIL FIXES UP TO ONE HU WR"THQUSAND DOLLARS <br /> 4100.000.),IN ADDITION TO THE COST OF COMPENSATION,Its MREST,ATTORNEY'S MES,AND DAMAGES AS I <br /> PROVIDED FOR IN SECTION 3706 Of THE LABOR Coor- <br /> „(CZ7 Ucerrscd eutharilMd reoPituntaft9),here&y <br /> autharlxe <br /> to sign this San Joaquin County Well PerrrmitA*Oilcat(an on tiny behalf It uhderstartd thin ssitherixatlun is V'o'id t'nt <br /> one(1)year*nd Is limltad to the work plan datad on tho!rant page of this app:lcatton <br /> 6.17.20001 MI <br />