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•- iu,oa rAA VIVII141U1 Z02 sort Joaquin Cotimy n �10�=nit IV Wel! Pirmit Appllcatbn SupplementJOB ADDRESS-^ �� gg D'E tT S S: LICENSED CONTRACTORS DECLARATION ( � I hereby affirm the I am wed udder the provisions of Chapter 9(oommencin9 with Section 7000)of Division 3 of the Business and Professions Code end my license is in full force and effect. License* 'T90q0 Expiration Date: 1.3U�CY> Dat.. ontractor: r_ i Signature: Title �lJ Printed name: V, i WORKERS'COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following deelarstions: (CHECK ALL THAT APPLY) I _I have and will maintain a Certificate of consent to self-insure for workers'oornpensatbn, as provided for by j Section 3700 of the tabor Code,for the performance of the work for which this permit Is issued I I �l have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, for the parfomtance of the work for which this permit is issued. My workers'compensation insurance carrier and policy num ber++saaare: ��1 Carrier: �GJG Policy Number•�t{lf�-J� t�Qrj_ Ili I certify that in the performance of the work for which this permit is issued, I shall not employ any person to any Manner so as to become subject to the workers'compensation taws of califomia, and agree that if l should become subject to the workers'compensation provisions of Section 3700 of the tabor Code. I shall forthwith comply with those provisions. Daft: Signature: Printed Name: -WXRWM:FAILUWTO SECURE WORKI&RS'COrApBNSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT � AN i1111111111PLOYt11it TO CRRAKAL PENALTIES AND CML FVIES UP TO ONE HUNDRffiD THOUSAND DOLLARS (5700.000.}, IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES As PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. I, (C-37)icensed authorized representative),heroby authorin to sign this San Joaquin County Well Permit Apolostlen on my behalf. t understand this authorisation Is valid too one 1 ear and is lhntted to the work plan dated on the front page of this appmestion.