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n oS .. _ uhf <br /> San .J in Cou Enviror ental Health Servlcas, Unit IV Walt Permit Appliradon 3appiamerlt <br /> J0E ADE31ESS: - A4RMT i sm <br /> LI1^E211g-SED CONTRACTORS DECLARA7310iN &Q <br /> t <br /> 1 hereby affirm that I am Il=nsed under the provisions of Chapter B (commencing *LS Section 70(30) of DivislCn I <br /> 3 of to Business and professions Coda and my license is In full force and affecL <br /> License * Expiration Dots ! � / �/ 1p� r -. <br /> IF- i . <br /> bate; 17 ) Ca atractor. TLl <br /> Signature: 114411 . j <br /> I kite: il� t�R <br /> Printed name: W <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury ono of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to selGinsurs for workers compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued- <br /> V 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' compensation insurance <br /> carrier and policy numbers� 10 aiu/I , <br /> Carrier; I 1 Q /f <br /> _r� Policy Number: We, ��r b D <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in <br /> any manner so as to become aubjeat to the workers, compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. ) <br /> Data: Signature: <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION OVERAGE IS UNLAWFUL. ANO SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES up TO ONE HONDRED THOUSAND DOLUWS <br /> (31001000.), IN ADDITION TD THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PKOVIDEO FOR <br /> tJR, IN SECTI/OJc,t..-L/ C/ <br /> N 3'tI7006 OF THE LABOR CODE4 <br /> Maet, trrz, ,// (C,%57 licensed authorized mprwantNM)a hero6y <br /> auttrOdSO {75 d Va "on <br /> to sign this San Joaquin County Well Permit Application cn my behalf, 1 undersand thea aufhori7-atton is valkl for <br /> one (1) year and is limited to the work plan. dated on the front page of this application. ', ` <br /> 547-2000 1 M1 <br />