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i-1 "-2C'O 12: 19A FF.OI' F:•_-." ENv-FONMENTAL 204772=57, P. <br /> R ' Z Pna,M i d C. $3$ q,%? Jul. 1'l 2PN10:0E++ <br /> San hl#n County Env' OCmental Health Servi s,Unit IV Well permit Appllcatim Supplement <br /> i <br /> jOB ADDRESS; PERMIT SRk 1 <br /> r r I <br /> r <br /> } <br /> LICENSED CONTRACTORS DEM-ARATI4N (LCD) I <br /> I <br /> { ! hereby a"frm t`^.3t 1 an;icensee under the pravisicns cf Chapter 9 (car:mzncing w:tis Section 7000)pf Civis,cn <br /> +� 3 of;he Business/anC Zrofessicrs Cove and my license is in fust force and effect. <br /> I license#. {_p 83 5 Expiratior Dates 1 Z3 fr 1-7 n7y-z-- -- <br /> Date: 11l1�a Car,tractor: �-i ( titil�i f b�- c tom` i <br /> Signature' `{ Title' bca►av�c r - <br /> fPrinted name: 2�1 c- <br /> r <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of peri-iry one of the fofiowinc declarations: (CHECK ALL THAT APPLY) <br /> I nave and will mairmi a ce-Vicate o°consent to setf-�nsure for wC-rkers'C7mpen3ation,as p^ov4e0 for 5y <br /> ~/Section 3700 o`. the'-abcr Code.for`he p•w � <br /> forriance of:he crk for which t`•,is perm;:s issued. <br /> ✓ <br /> 'Inave and wit maintain worker'compensation irsumnce,as regjireO by SBttion 3700 of L`.e Labor Code. j <br /> for,,he performance Cf the worts fcr whicr :hrs permit is;ssued My worcem compensat or, insurance <br /> carrier ana poucy numbers are <br /> Carrier: n, Pocky Number. 1�3G 2O5`� <br /> i <br /> k _1 -eetify that in the performance o'tie work for whiCYt thie perMit is issued, I Shall not employ any persoin <br /> any .-nanner so as to becorne sub'ect`.o tl-,e aorke-s'coripensaUcn!aw3 of Cai;fornia,and agree trai if n I <br /> sncu'd cecorne subjec to the wcr%ers'aornpensatian provisions of Sec'iQn 3700 cf:;,e Labor CMe, I sha11 { <br /> I fortnw,111 comply was tncse prov,sions. <br /> I <br /> I Date: signature:, <br /> Printed Name: <br /> WARX04G_FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,ANG SHALL SVBJECT <br /> I AN EMPLOYER TO CRIMINAL P=NAL'rl£S AND CIVIL FINF-S UP TO ONE R-UNCREb THOUSAND COLLARS <br /> {3100,000.),IN AL`DITION TO THE COST OF C061PENSATION,INTEREST,ATTORNFY'S FEE3,AND DAMAGES AS <br /> 1 PROY10E0 FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I <br />