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JRCi 17 21702 15: 15 GRl GG IJR I t_L i NG3253' 30302 p. 3 <br /> lay-�NM.141?225 140DESTO ATC 1%� PAGE E2 <br /> San Joaquin County Envfronmentat Heakh Services,Unit IV Weil I'ermtt Applieat7on;Suppfemant <br /> JOBADDRESS: �.��I l �r�tit Tt•.,c PERMIT s>R#: 6 g925 <br /> LICENSED CONTRACTOWS DECLARATION ' (LC <br /> I hereby affirm that 11m licensed under the proviaians of Chapter 9 (commencing wNh Se[tbn TQQO)of Divis#on <br /> 3 of the BUS!MOSS and PrDfesslotss Code ertz+my fir is fn full force and effect <br /> License tr: 61r ? <br /> ExOfratian Cate: I <br /> Date: Contractor: <br /> Stgnattt re: <br /> Title: <br /> Printer!name: <br /> WORKERS'COMPENSATION DECLAPAT104 <br /> I hereby affirm under peneiry Of penury one of the following deciarationa: (CHECK ALL THAT APPLY) <br /> I have and will maintain S 09MOcate Of consent to self-Insure for workers'COMponsatfon, as provided for <br /> Section 3700 of the Labor Code,for the performance of the work for+vhlch this permIt Is IS.SUBd, by <br /> l have and will MaintglM workers'Corrlper+sation insurance,as required by Section 37G0 of the Labor Co <br /> for the an Polis tca m the work for which this permit is issued. My workers'Compensation insurance de, <br /> canter and policy numbers era; <br /> Carrier• Policy Numbea• <br /> I ceKiF that in the d <br /> y performance of the work for which this permit b fssued. I shall not ernptoy any person in <br /> any manner no as Io become subject to the workers' scion jam of California, and agree that If <br /> should become subtest ED the workers'compensation provisions of Section cornpiy with those PrOVISIon s. 37QC of She Leiser Code, f snap <br /> forthwith <br /> Date•-- i ! / L .Signature: <br /> I Printed Name, <br /> f <br /> WARNING,EMPAttlLlRE I SECURE Wi3RKE"'CONPENSAT10M COVERAGE 13 UNLAWFUL,AND SMALL SUSJEC7 <br /> AN EIMPLOVER D CRIMINAL PENALTIES A140 CIVIL FINES UP To ONE HUNDREp TmQUSAND aOLLgRs <br /> (S1 tlp,Ot?O.],IN ADO1T10iV TO 7"I!COST OF COMPENSA1fON,iNTERIMT,ATTORNEY'S FEES.AND FJAMAGIrs AS <br /> PROVIDED FOR IN SECTfON 3706 OF THE L"OR CODE. <br /> F <br /> 1, <br /> RC•S7 <br /> authaia• ticenaad authorised raPre2entatlV6),hereby <br /> to elfin this San Joaquin County Well P•rfnrt Apphlcatfon an my Ashatf. I understrnd this iFuthoftatian is valid for <br /> on.(i)year and is 111rrllod to the workthin gq o <br /> Ian daead on the trortt psf <br /> p rPOtlCatlan. <br /> 577-30CD 1 Ml � <br />