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CL IN GPOUP 1B3i5o2-9179 NO.25a D0? <br /> • <br /> San Joaquin County Environmental Health Department Unit W Wall Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#:-003W0' _ <br /> ONOO qo <br /> LICENSED CONTRACTORS DECLARATION LCD <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 Prolicense <br /> otessalons Code and my Is in full force and effect. / <br /> License 0 / / !Q ��-- Explration Data' <br /> Date: l ` '� Cant r_ �JIiV . tQr+�77tt�t AS iv C x-, <br /> Signature: Tltlo: JP245 <br /> Printed name: l t��-- 711 (E �� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratlons: (CHECK ONE) <br /> I have and will maintain a certlficate of consent to self-Insura 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 /> X 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'compensabon insurance <br /> carrier and policy numbers are:. <br /> carrier. r 1� �,DALP. . +U S- r-' Policy Number: ip I 1007-63 <br /> 1 certify that In the performance of the work for which this permit ie 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 ff I <br /> should become subject to the workers'compensatlon provisions of Section 37 of the Labor Code, I shalt <br /> forthwith comply with those provisions. <br /> Exlslratlon Oats: 2 <br /> —L0Lz D S Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.A14D SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (s1QD,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTO"EYS FEES,AND DAMAGES AS <br /> PROVED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, 61 1�2 (signature afC-57 licensed authorized reprsasrrtattvaL <br /> haraby authortro(print name) At I G H PIC 4,05c gf-A2 6 C� aR l�lU#J t FE 2 Lfi!? <br /> to sign this San Joaquin County Well Permit Appllc4on on my behalf. I understand this authorixadon Is vaild for <br /> one(Z)year and Is Limited to the work plan dated on the front page of this application. <br /> 4.29-02/MI <br /> EFD Z4-QZ-0aI <br />