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Son Joaquin County Environmental Health Services,Wdt IV Mteit Permit Application Supplement � <br /> JOB ADDRESS: G G� ( ,� CC T -�i PERMIT SR#: 2 g1o _ <br /> r <br /> I <br /> LICENSED CONTRACTORS DECLARATION <br /> I <br /> I nereby affirm that i am iicensed under the provisions of Chapter 9(c*mmencing with Section 7000)of Diviseon <br /> 3 of the Business and Professions Code and my license is In full force and effect. <br /> License#: -17L9o9(9y Expiration Dute.__ /I&L)2 <br /> iVats: Contiactor. Lf 8 LJ Ii'r 1 JI/Viy, 1/-�C — --- -- <br /> Signature: -� ��. yw� Title: J�A44AZU,,V A.,, � <br /> i Printed nonose JdCkJ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm ander penalty of perjury one of trio following daciarations• (CHECK ALL THAT APPLY) l <br /> I <br /> _I have and will maintain o certificate of consent to %*&insure for workers' compensation a6 prov;ded for oy <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued <br /> I have and writ maintain workers'compensation insurance,as requires try Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issues My workers' compensation insurance <br /> carrier and policy numbers are: <br /> 1 <br /> Carrier: ��� _.�........�Policy Number: U��'�`�� `�-��J <br /> i <br /> i <br /> 1 certify that in the performance of the work for which this perm t is issued, i shall not employ any person m ! <br /> any manner so as to become subject to the workers' compensafem saws of California, and agre&that if i <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shat; <br /> forthwith comply with those provisions <br /> Date: signature- _ 1 <br /> tarinted Name. <br /> WARNING; FAiLURE TO SECURE WORKERS'COMPENSATION COVERAGE I8 UNLAWFUL,AND SHALL SUBJECT <br /> AN @IMPLQYCR TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRCD THOUSAND DOLLARS i <br /> 4100.000),)h ADD)TiON TO THE COST OF COMPENSATION, INTEREST.ATTORNEY'S FEES,AND DAMAG ES AS � <br /> PROVIDED FOR IN SSCTION 3708 OF THE LABOR CODE. <br /> 1, C-37 licensed authorized reprsprttallve),hereby <br /> authorize Mme?. [/J t�('dw,y .C.��tZ� f t• _ <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> L one t1)year and is limited to the work plan dated on the front page of this application. <br /> i <br />