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San Joaquin County Environmental Health Departiroent Unit 1V Well Permit Appli cvioli Supplerno nt <br /> JOB ADDRESS: 1T`1 70/kx. P811MMIT SRO:-- <br /> LICENSED CONTRACTORS DECLARATION i;.!=�Q <br /> i hereby affirm that t am iicensed under the provisions of Chapter a(commencing with Section 7000)of Div sion <br /> 3 of the Business and PrrsfessiOrm Code and my license is in full fares and affect <br /> License#, 7 ZZZ5& EVration DatE. <br /> fie: 0`l Con tor, L �I IG/ <br /> Signature: <br /> 14 <br /> I�rtntetl Hants. ��1�� <br /> WORKERS'COMPENSATION DrECLAR,41I0N <br /> 1 hereby affirm under penalty of perjury one of the failovAng dealmdona; (CHECK ONE) <br /> I have and wilt maintain a carlificratt of aoroir"to ewlf-insure for warlit r'cornpeiisafion,as provided 13r <br /> by Section 3700 of the Labor Coda,i to the performance of the worts for which this permit is issued. <br /> I havo and MY oirrtain workers'compensation insurance,as required by 5ecnan 3740 of the Labor Cc Pde, <br /> for the performance of the vmrk for which this permit is issued. My workers'corrlp ensation insurance <br /> carrier and policynumbers <br /> /are: <br /> Carrier:�i�r�/�/yrl �/�i W iftiricy Number. .��..�QJ��I <br /> I csrtifjj!hat in the performance of the work for which this permit is issued, I shall rout employ any petsat r in . <br /> any rnannmr so as to becorno subject to the workers'compensation town of Ulfornia, ane agree that if I <br /> shoc,dcl Woome subject to the workers'compensation pmviSiont of SeW an 3700 cs the Labor Code,I s call <br /> forthurfrth ply lth those provisions, a <br /> SignatunM: ..� <br /> tented dame: 74o4l ` toe <br /> WARNING:FAILURE TO SECURSWOMERS'C0M1PEMATIt3N CO1/ERAtaE M UNLAWFUL,AND SMALL lallsil-.0T <br /> AN EMPLJDnR TO GFtMNAL PENALTIES AND CN&FINES Up To ONE HUMRED THOLiSAtYla DOLLARS <br /> ($100,000.),IN ADDITION TO TFils C08'r OF COMFERSATION,INTEREST,AThORNRY'S FlzFS,AND DANWGES,W <br /> PROVIDED FOR IN SECTION VW OF THE L.ABM COOF <br /> A HORIZATI I=O�R �H THAN C�67 SIGNING PERMIT APPLICATION <br /> I' (signature W-67lieen8e-4 authorizad re <br /> preseutatl moi► <br /> hereby authorize(print name) <br /> to sign this San Jaaqulrl Cou ty WIgi permit Apptication on 1111r hebalf. 1 understgnd lI1I�tcixtharizatloa is wdPd f.Pr i <br /> one(1)year and is limited to vw grails plan dated on the evn,t page of this applrcaganl <br />