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�o <UVff 1Kt..Ll 7L7-u6.i-Lhh7 AIL; WLt-AbANILIN YLri7t 04 <br /> sen jcaquin County Rttvlronmsntal Health F; kes.Uillt N Well permit Agpitcation supplement <br /> JOS At'ibRE55: �I`/�Qfl7I�18!' LCiAe PERNUT SWGQ 1? P+'' <br /> �2 <br /> LICENSED CONTRACTORS DECLARATION (LO) <br /> I <br /> hW*W*Mrm that I am licensed under the provisions ofa���(commencing <br /> andwith Section 7000)of Division <br /> 3 of tial Business and Prvfetsde—sionS Coand try Oc*"e is in <br /> License rf a Ewwation Date: r 31 <br /> Date: Z: p� Contractor r r 4 <br /> Title. <br /> Signature: , <br /> Printed ttatn0:.�.,I JIr1/1/lJ �/��'N <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby aMrrn under penalty of perjury one of the following doclatations: (CHECK ALL THAT APPLY) <br /> have and will maintain a certiflcateof content to self-insont for workers'oompeniation.as provided for by <br /> /Section 3700 of the lati0t Godt.for the perfore WAM of INe work for Which M pent it is issued. <br /> ✓i have and wilt maintain workers'cornpen"W"insurance,as required by Secfion 3700 of the labor Code, <br /> W the performance of the work for which this permit is issued. My workers compensation insurance <br /> Carrier andicy numbers are: c� _ <br /> Carrier: 1 C' / ocyNumber: <br /> 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 become subjaat to the workers'compensation laws of Califomie.and agree that if I <br /> Wvuld.become lA00 to Me workers'corrfpertsi0on pr vlslons of n 9 of the Labor Code,l Shell <br /> forthwith oo mly wo those provisions. <br /> Date:_r^ _ -L?l) Signature' <br /> Printed Name• ?^,i�l <br /> wARMNO:FAILURE TO SECURE WORKERS,CoWilijOATIO"COVERAGE 0 UNLAWFUL,AND smAL L SUBJECT <br /> AN IMPLOY6R TO CRiMiNAE PENAL.TWS AND CIVIL FUM Ur TO ONE HUNORED THOUSAND DOLLARS <br /> (S10o,000,L M AOOMON TO THE COST OF COM►ENSA'nON.1ATMREST,AT nonngK'S FEM AND DAMAGES AS <br /> ~VIDEo FOR W WXTION 3706 OF THE i.45OR OOOC <br /> ,C47 irr enaw suillo and mange Mali 4 hereby <br /> i.. <br /> to sign chis Son Joaquin County wall Parnrit ApPr4ation on my bshatf. I!understand this suMorIMSOn Is valid for <br /> orw(1)year and is pmlted to the work plan dated an the front BM of this <br />