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`.a' <br /> Sart Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLtCA T[ON SUPPLEMENTAL <br /> JOB ADDRESS: 3,,15-0 We-Sl- ljg, .4#el La L-. PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATIONL( CDS <br /> 1 hereby affirm that I an 1lcensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Corse and my license is In full force and effect. <br /> License r s 6z's's-1 Exp Date:-LV st r t <br /> Date_ 1261L: <br /> Signature_ ' <br /> Print Name> }�,1��hG�1 A(��1�]h. <br /> WORKERS'COMPENSATION DECLARATION <br /> hereby affirm under penalty of perjury one of Lha following declarations: (check,one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code. for the performance of the wort:for Which this <br /> permit is issues. <br /> t have and Witt maintain We kers' Compensation tasurance, as requirad by Sec;,ion 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> car6er:,6 1WOC 1 +44Atfd 114 T u¢.in Policy Number: ZZ IrJJ5V%-1h%&00( <br /> 1 certify that in the performance of the work for which;his permit is issued, I shah reit a nplpy any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> and agree that if i should become subject to wor kers'compensa`.ion provisions of Ser-don 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp.gate- 1OIt Signature: r •� <br /> Print Name.:E;,b.% t,► ►No lt31���C, <br /> WARNING:FAILURE TO SECURE WORY,ERS'COMPENSATION COVEP.AGE IS UNLAWFUL,AND SMALL SUBJECT AN-EMPLOYER To <br /> CRIMINAL PE;;ZTIES AND CIVIL FINES UP TO$104,000, IN AUDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF-RiE LABOR CON. <br /> A 1 "'IO OR OTHER THAN C-57 SIGNING PERHtt i APPLICATION <br /> (signature of C-67 licensed authorixvd representative), <br /> hereby authorize(print name)Alvy , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this'hAthorizatton is valid for ons year and is limited to the work <br /> plan dated on the front page of this application. <br /> er4:;t+in Crs,a <br /> YlLll�(�T L i� <br />