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JOB ADDRESS ::�t - PERMIET'�Wit. <br /> .���. :;�: _- _ear:_ .r•,--,: •.;•• :;�-- - ..a::.: _-. :'y�: _.;�. <br /> �IY.::�:•. ,?Y. �.~��.,q,.a�w n�A�V—�-:..7 V ., . .+',!.: .......�...n. .....m r .:�...w ....r..._�. .nr ... .. <br /> LICENSED CONTRACTORS DECLARATION (LC <br /> I hereby affirm that t am licensed under the provisions of Chapter S(commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code) and my license is in full fora and effect <br /> License 0: Expiration Date: 4 <br /> Date: Contr r. ,(',�,�� 131 Or a-&t-.A�&A <br /> Siiaatum:-- --- Title: AA.W�d"a r <br /> Printed name: <br /> WORKERS` COMPENSATION DECLARATION <br /> I hereby affirm under pef*Ity of ptrsury one of the followln9 declarstions: (CHECK ALL THAT APPLY) <br /> i <br /> I t'ave and will maintain a cenificate of consent to self-insure for workers'eornpensation, as provided for by 1 <br /> Section 3700 of the Labor Code.for the performance of the work for which this permit is issued. i <br /> .41 trove and will malnta`n workers'compensation insurance,as rewired by Section 3700 of the Labor Code, <br /> for the performance of the work for which this perrnit is issued. My workers'compensation Insurance <br /> carrier and policy numt>ers are: <br /> Carrier: Policy Number; <br /> I certify that in the perlormance of the work for which this permit It Issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and 69ree that if I <br /> should become subject to the workers'compensation provisions of ion 3700 of.he Labor Code, i shall <br /> fonhwlth Comply with those provisions. <br /> Date: .TeA,, �Sq,—. Signature: <br /> Printed Nam*: <br /> WARNING: FAILURE 70 secURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND$HALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENAL71ES AND CIVIL PINES Up To ONE HUNDRED THOUSAND DOLLAR$ <br /> (S'IDD,000.), IN ADDITION TO THE COST Or COMPENSATION, INTEREST.ATTORNEY'S FEt=S, AND DAMAGES AS i <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> r <br /> I. n� -%A ►-,! (L ii 11 (C-57 licenit ha!der), hereby <br /> suthorlte_ds1k V► Ra of . �.. _ – (consulting),to sign this San <br /> i <br /> Joaquin County Well Permit Application en my behalf. 1 understand this authorization is valid for one ti?year <br /> I <br /> and is Ornited to the work pion dated on the front page of this application. <br /> ti <br /> TVT0 7tid N01}I301S 30V 8111[911?5ec 4P:L1 688Z/6T/T0 <br /> Z0 30Vd ? 00000000000 9V:90 000Z/1T/T0 <br />