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two F <br /> I L E <br /> San Joaquin County EnVirontnentaf Health Sorvicac,unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#- <br /> - LICENSED CONTRACTORS DECLARATION (LCD1 <br /> (hereby affirm that I em licensed and©r theisrnvisibris of Chapter 9(commonalty®with Section 7000)of Division <br /> 3 of the Business and professions Corse and my license iq 1ri full force and effect. <br /> License#: S `�`�7 Expiration Date: <br /> Drags: b�'a 2 a/ Contractor <br /> Signature- <br /> r- <br /> printed name: U-_rt+`�0 dit1L�T7 <br /> WORKERS' COMPENSATION DECLARA'nON <br /> I hereby affirm under penalty of perjury ons of ttie following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for by <br /> Saction 3700 of the Labor Code,for the performanre of the work for which this permit is iswuud. <br /> ave and will maintain workers'compensation insurance,as required by Sfr-tion 371)0 of ern Labor Code, <br /> for the perrormance of the work for which this pemrit i:s issuerd. My workers'compensatlon Insurance <br /> carrier and policy numbers are: ,D <br /> 60 0 <br /> 'J-Lu tom. policy Number: / ✓Y'� 1�� 98����6 Z <br /> Carrier: // +1 __.. ... <br /> I certify that in the performance of the work for which this parmlt is issued,I shalt not ynrploy any person in <br /> any manner so as to become subject to the workers'compensatlon lawns of California,and agrees that It I <br /> should become subject to the workers componantlon provisions of Section 3700 of the Lasbor Code,I shall <br /> forthwith comply with those provisions. <br /> Date: Q;,/-off a f -_.. Signature: <br /> Printed Name: <br /> WARNING-.FAILURE TO SECLIR'F WORKS <br /> mpCVERGE13LAWL,AND <br /> SHALL <br /> s BIECT <br /> AN EMPLOYERTO E AND _NN=B UP OONE E THOUSAND DOLLARS <br /> IN ADDITION TO THE COS" <br /> OF COMPENSATION.IN7>=Ms3,ATTORNEYS FFF4,AND UAMADES A <br /> pROVIDED FOR IN SECTION 3706 OF THE LAI13014 CODE. <br /> 'n pA_L-r't f,*-1, — (C-til Licensed authorized mpiesentative),hereby <br /> authorim /GL _ <br /> Han an my behalf. I undonatand thio authorixation is veitd for <br /> to sit this San Joaquin County Watl Permit p,ppite�r <br /> one(1)year and is limited to the work pian•juled on the front page of this applicatlorl <br /> 5-i7-20K.1 MI _ <br />