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Sam n Joaquin County Environmental Health Department Urit 1V VfeR Pe <br /> it App#Icatinn Supplement <br /> JOB ADDRESS -- - --- - PERMIT S12#:- -- --- <br /> I <br /> i <br /> LICENSED CONTRACTORS DECLARATION (om) f <br /> I herety affirm that I am licensed under the provisions of Craptsr 9 (commencing, wceh Section 70001 of DIVISior, <br /> 3 of the Business and Professions Code anc my license is in ful °orce and effeci. <br /> fLicense # C--L' 7 Vejc d F_xairaticr Date <br /> Date: Iy ;� Cnaact / ! 1 r� <br /> 1 71- <br /> Signature; <br /> G�^t tf�ZZ Title: rfr r- /✓1�nG� �u,-- <br /> Printed name: - <br /> WORKERS' COMIPENSATION DECLARATION <br /> I hX�y <br /> eerety arfrm under penalty of perjaryone of the following declarations: (CHECK ONE) <br /> ave and will mairtaln a certificate of consent to self-Insure `c•workers' camp°nsaticnasprovided for <br /> Section 3700 Cf the Labor Code, for the performance of the+nark for which this uermi' is :ssued <br /> i <br /> have and witi mairtaln workers' compensation insuran-e. as required t:y Sector, 3700 of the tabor Cotte. I <br /> for the performance of the work for whicri this permrf is Issued. My wo,eers'cvmpensatior insurance <br /> Carrier and policy nurpbors are: <br /> Carrier: -_ __--- yPolicy Number: <br /> ( Certify that in the performance of the work for which this penit is :ssuea, l shall not emoloy any pets-or in <br /> any mainer so as to oecome sutject%o the workers' co rperselion ial of Celifornii and ag•ee that if ! <br /> should becorne subject to ;he workers' corn Jensatan provisiO's o`Sactior 3700 :)f.fie labor Coda. ! shall i <br /> foal-with comply with those provisions. <br /> Expiration Oate: t - Signature; A AG <br /> Printed Name: . <br /> WARNING: FAILURE TO SECURE WOIQKERS'COMPENSATION COVERAGE 18 LINLA4V7UL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSANC DOLLARS <br /> i (6100.000.), 04 ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNFY'S LEES. AND DAMAGES AS <br /> PROVIDED TOR IN SECTION 3706 OF THE LABOR CODE. <br /> i <br /> I TIQi�I f3DR D?HEi? THAN C-87 SIGNING PERMIT APPLICATION <br /> I fes/' <br /> (signature ofC•67 licensed authortxed representative), <br /> hereby authorize(print name)_ j%A a{#IC A c t-ta, <br /> to sign this San Joaquin County Well Permit Application on my behalf, i understand this aulhoriza!ion is valid for <br /> one IT)year and is limited to the worl; pian dated on the front gage of this application. <br /> 8.29.02(MI <br /> EHii 29d)2�01 <br /> u%22FJzf <br /> I <br />