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} lo� <br /> San Joaqui❑ Gowlty Environmental Hasit.'S llepartmaat Unit IV Well PermitAppiicationpSuppie I nt ^ <br /> JOB ArJURss: ly�y 9 N. rn+r/ p ) <br /> c A- <br /> LICENSED CON-TRACTORS DECLARATION (L CDS <br /> I hereby affirm that I am ftcensed under the provgior,s of Chapter 0(commencing with. ection 7000) of Division ' <br /> 3 of the Business andel Professions Code and my. license is in full force and effect <br /> License At (� f Expiration Date: <br /> Date: /0 - 016 -0 COn Aor. t►tQd^tQ�0.p �fi; ( r ` <br /> Signature: Title: _!Yr<fA-t as Jy <br /> Printed name; <br /> -- —_ <br /> WOf2KER ' COMPENSATION DECLARATION j <br /> i <br /> I hereby affim, under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificats.ot consetltta Belt insure for workens' compensation, as provided for <br /> hb .,Secticn 3700 of ldw Labor Code, fort hq pe,formance of the wGrk far which thus permit is issued. <br /> ave and will maintain workers'comp6bsadon:insurance,as required by Section 3700 of the Labor Code, <br /> for ills performance cf the work for whl iillls_ :]ilsrfn it is Issued. Mywcrkars'Compensation insurance <br /> carrier and policy ltumbvrs <br /> rl <br /> Carrier: /Y 4 !s d CC Ili+.v Number: X <br /> I t certify that in the performance of the ytpl.'k for which this permit ie issued, I shall riot employ any Nrsonin{ <br /> any manner so as to become subjeotto hie workers'compensation laws of California, and agree that If I <br /> should become subject to the workers'zompensation provisions of Section 3TD0 of the Labor Code.I shall <br /> forthwith comply with those pmvislbns. <br /> Expiration Date: Signature_ <br /> Printed Mame: . f <br /> WARNING:FAILURE TO SECURE WORKERS'CCMPENSATION COVERAGE t3 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND 1OLLARt3. <br /> .(3'100,000.1,IN ADDITION TO THE COST Of COMPENSATION, INTEREST,ATTORNEY'S FEES,AN DAMAGES A3 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR <br /> OTHER THAN CwV SIGNING= PERMIT APPLICATION <br /> �/ / ,��f+_��t/s�fgnahrra ofC 57 licensed authorized representative], <br /> hereby authoras(print narffe) _.; <br /> to sign this San Joaquin County Well PennitApplicallon on my behalf. 1 understand this authaxUatlon is valid for <br /> one(1)year and!•9 limited to the work Akan tfafiad or_i,ffie front page of this.application. <br /> fl 1 MI <br /> &22M <br />