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J.?i<'t,i2G119_ u'd. . :i �1La61�1 • <br /> i-I-CI II: � r'AGi. Ci kt ' <br /> Z31 Z�� ZS 29. 65129.0� <br /> San Joaquln County Environmental Health Department Unit IV Well Permit Application supplement <br /> JOB ADDRESS:—.. PERMIT SR,#: Qng33 (o I <br /> LICENSED CONTRACTORS DECLARATION (LGQ) <br /> I horeby affirm that I am licensed Linde., the previsions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of Ute BUsinsass' acrd PrOfeslsf-I}pns Cod"..and my license io in full force anlfd Rect t 11 !//1 <br /> l.lcense St: O� LIE <br /> ': lo` 1 r�ErP atro^Uai `.'1 6J l..dr <br /> Contra or, _..� <br /> Signature:_ Title: <br /> Printed name: <br /> WORKERS' CQMPENSATidnl DECLARATION <br /> I hereby affum under penalty of padury one of the followtrlg 4jeclaratlpn5; (CHECK ONE) <br /> t he"and will maintain a cartfcate of consent to self-insure for workers' cc mpetr ion, as provided for <br /> by Section 3700 of the Laber Cedo,for the performance of the work forwhicl thin permit Is Issued. <br /> I have and will maintain workers' oontipensatten insurance,as required by Section 3700 of the I abor Codc, <br /> for the performance of the work for which this Pem'lit is issued. My workers'compancatx:n insurance <br /> carrier anSLPolioy numbs aro: <br /> Carrier: LL cl Pollcy Number: <br /> 1 cariry that in tho performance of the work for which this permit is issued, I shell not employ any Person in <br /> any manner so ac to become sub)ectto the workers' compensation laws of California, and agree that if I <br /> should become sutlect to the workercompensa i <br /> son provisions of A•flan 3700 of the Labor Ccde, I shall <br /> forthwith comply with those pruvisions. <br /> — <br /> Printed Name:. <br /> WARNING:FAILURE T'O SECURE WORKERS' COMPENSATION COVERAOE IS UNLAWFUL,A D SHALL 5UBJECI' <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINF.S UP TO ONC HUNDRED THOUSAND DOLLARS <br /> (S10Q000J,IN ADDITION TO T7-JE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 7706 OF'THE LABOR COD[,,. <br /> /THORIZATIO FORPTH THAN C-57 SIGNING PERMIT APPLICATION <br /> 7 _ 1—{signature ofC-Si licensed authorized reprpsonkrltiYs), <br /> herebyeYthorize(printname) \)NCAN—L��KM-- <br /> to.sign this San Joaquin County Well Permit APPlleation on my behalf, I ilnderslund this ouUmrirotion is valid for <br /> one(1)year and Is limited to the worK pian daod on fhe front pogo of thea appncatlan. <br /> CEO 52221 741002 <br />