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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SRS_ II <br /> I <br /> LICENSED CONTRACTORS DECLARATIONL{ CD! <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect f p <br /> Ucense# �85/ZO� Expiration Date <br /> Date: Contra : <br /> Signature: Title: <br /> }} r <br /> Printed name: x/.41 <br /> WORKERS'DOMPENSAVON DECLARATION <br /> I hereby affirm under penalty of perjury one of the fc0owimg declarations: ICHECK ONE) <br /> _I have and WO maintain a certificate of consent to seNansure for workers'compensation.as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> J I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation Insurance <br /> carrier and policy numbers are: rz <br /> Carrier: CZ 'u" la K t— Policy Number: p L(pf <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 subject to the workers compensation laws of California, and agree that if I <br /> should become,subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> fora Wh comply with those provisions. <br /> Expiration Date: Jl J/o Signature: <br /> Printed Name; <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> ! AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ft1DU,000_),W ADDITION To THE COST or COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR Ar SECTION 3706 OF THE LABOR CODE. <br /> AUUTHORIZA71ON FOR OTHER THAN C-47 SIGNING PERMIT APPUCAT10N <br /> 1 , 111;1 !lf ,� - _fslgnmraoAG670censcda omftedrepresemative), <br /> Neaeby aupwrim(print <br /> to sign this Son Joaquin County Well Permit Application on my behalf. t u d this authorfzattan Is valid for <br /> one(1)year and Is Ik~to the work pkm dated an the front page of this application. <br /> 949421 MI <br /> tamZ 2-WI <br /> 61724t <br />