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2-15-205 2:49PM FROM P_ 2 <br /> r J. 2JV:i t 1�+'iV CJi �►� ;� it�N W, �3/) r. 1 <br /> .ri29ra Joaquin County Environmental Health services,Unit IV Well Permit Application,Supplement . <br /> JOB ADDRESS: Q- Sma4 5k��a� a 0'sk PERMIT SSR#: <br /> LICENSED CONTRACTORS DECLARATION (LC � <br /> I hereby affirm,that.I am.licensed under the provisions of Chapter 9 (commencing with.Section 7000)of Division <br /> 3 of the Rusines(ss aand.Prro�fmloris Code and my license is in full force and effect_ <br /> Licesnsa.t�: t� �(:! tG1 Expiration Date_ <br /> Date: ` '� _ Contractor: <br /> Signature~�� l Title: <br /> Primed name__. �ci li <br /> WORKERS' COMPENSATION IDECLARA'TiON <br /> t hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-irrsvre for workisrs7 compensation,as provided for by <br /> �.Section 3704 of the.Labor Code,for the,performance.of tree work-for.which,this permit is issued_ <br /> .,�Zl have and will maintain workers`compensation insurance,as required by Section 370.0 of the Labor Code, <br /> for the performance of the worst forwnich this permit is issued:- My workers'compensation insurance <br /> carrier and Iic nurnbe s..are: <br /> Carrier.. ^ Policy Number, _­ <br /> 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 I3ws of California, and agree that if I <br /> f should become subject to the workers'.compensation provisions of Section 3700 of the Labor Code, I shall <br /> l forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed Name.:�V-1 <br /> WARNING-FAILURE TO SECURE.WORKERS'COMPEN$A7TON COVERAGE IS UNLAWFUL.,AND.SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000_),'IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A5 <br /> PROvlop-D FOR IN SECTION 3706 OF.THE LABOR CoQ£. <br /> I, /, ►' (C.57 licensed authorized representative),riereby <br /> authi2rlao- i i CQ40r, t Nb, . <br /> tea sign this San Joaquin Oounty Well Permit Application on my behalf_ i understand this authorizatlon Is valid for <br /> one.(f)year and Is limitad to the workplan dated on the front page of this application. <br /> 6-17-20W I Mi <br /> RECEIVED TIME FEB. 15. 2:44PM <br />