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pz - &4iZ7- <br /> lf�ew_ 14 <br /> San Joaquin County Environmental Health Departing it Unit IV Well Permit <br /> JOB ADDRESS: Application Supplement <br /> PERMIT SR#. Ob0& / <br /> Z <br /> 6(J <br /> LICENSED CONTRACTORS DECLARATION89S <br /> LCD <br /> 3 of the Bus essrm at I am and Prlofessions Code and myunder the rsions of license is n full forcand effect. <br /> P (commencing with Section 7000)of Division <br /> License#: <br /> -- <br /> Date: Expiratic i Date: <br /> Contractor <br /> Signature: ' <br /> f _ <br /> Printed name: Title: <br /> WORKERS'COMPENSATI(IN DECLARATION <br /> I hereby affirm under penalty of perjury one of the following d.:ciarations: (CHECK ONE) <br /> _ I have and will maintain a certificate of consent to self im wre for workers'compensation as provided for <br /> by Section 3700 of the Labor Code,for the performance ,f the for which this permit is issued. <br /> I have and will maintain workers'compensation insuran , as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this perm is;.ued. M workers' <br /> carrier and policy numbers are: Y compensation insurance <br /> Carrier: <br /> Policy Number: <br /> I certify that in the Performance of I ,work for which this )ermit is issued, I shall not employ an <br /> any manner so as to become sub' ,I to the workers'com sensation laws of California and agree that f I <br /> should become subject to the P y Y Person in <br /> forthwith comply sitars'compensation pros inions Of Section 3700 of the Labor Code, i shall <br /> P y with those visions. <br /> Expiration Date: Signature; <br /> Printed Name:_ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION"OVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER DD CRIMINAL PENALTIES AND CIVIL FINES UP"O ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED <br /> IN ADDITION TO THE COST T E COMPENSATION,IW ERE3T,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> ALITHO ION FOR HAN C-57 31GNING PERMIT APPLICATION <br /> (sig iature o,fC•ti7 licensed authorized rsPresentative), <br /> hereby authorize(print name) t Y �, 1 ` i, ,n � iL <br /> to sign this San Joaquin County Wall Permit Application on m M <br /> One(t)Year and u limited to the work Plan dated on the front Y .half. 1 understand this authorhatlon is valid for <br /> Peg)of this appilcatlon. <br /> 9.29-02/MI <br /> EHD 29-02.00i <br /> 6/22/04 <br />