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01/C4/0b 15: 59 F,a 916774101 <br /> San Joaquin County Environmental Hsaith SerYlCes, knit IV Well Permit Application Supplement <br /> JOB ADDRESS e l�Y �rL PERMIT SR#: I <br /> i <br /> /oo �-�r�e l�t�. o o•x�o <br /> 1 LICENSED CONTRACTORS DECLARATION (LQD) <br /> I hereby affirm that?am !icansed under the provisions of Chapter 8 (cmmer.cing with Sectior, 7000!of a7ivis+ten <br /> i 3 of the Sisinens and <br /> �P ofessiors Code and my license is in fuu farce and effect- <br /> License 0. c9Oat/l'7 Expiration Dct'e <br /> i Gate: _contractor I <br /> Signature: <br /> I <br /> Printed name: ��tTl� _!� - -.r _ <br /> WORKERS' COMPENSATION DECLARATION j <br /> f <br /> I hereby aff rm ender penalty of perjury one of the following daciarat,o7q (CHECK ALL THAT APPLY) <br /> I <br /> 1 _I nave and ww maintain a certificate of cursent ,o saif-insure for wor,cers' compensation as Prov ded for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued j <br /> I nave and wO maintain worker&'Compensation insurance, as erli red by Section 3700 a' the Labor Code. <br /> r fur the performance of the work for which this permits issi ec fAy workers' comper.sation insurance <br /> :airier and pciicy numbers are <br /> , <br /> Carrier. Cp1der, Q ,Policy Number. 'llttll -5�l� �; 5 <br /> i certi?'y that in tt^e performance of the work for whirr th%perm t i% ssoed, � shali not employ any person n <br /> any manner so as to become subject to the workerscompensat;cr laws of Cai;forniaand agree that if I <br /> should UeCome subject to the workers comoensatic�n provis;ens of Section 3700 of the Labor Code. I shat' <br /> forthwith cornciy with those provisions I <br /> Date: Signature: j <br /> Printed Name.• <br /> WARNING: 19A11LURE TO SECURE WORKERS'CONIPF-VSAT?ON COVERAGE 1S UNLAWFUL,AND SHALL SUBJECT � <br /> AN 9MPLOYER TO CKIMINAL PENALTIES AND CIVIL FINES UP TO DNF HUNDRE-D?NOUSAND DOLLARS ! <br /> (i100.000.y,IN ADDiTiCN TO T146 COST OF COMPENSATION, WTERE9' ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVICED FOR IN SECTION 3706 OF THE LABOR COCE. <br /> I, (C•57 licensed authorized representailve), hereby <br /> authorize �. �i'/�iD-</cd'•L1� "_- GLP4 S OG lit. <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> L one(1)year and is limited to the work plan dated on the front page of this appticat;or. �_ <br />