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San Joaquin rounty P'nVim"rnental Health Department Unit IV Well Permit.A;,00 rti[in supp it-me it <br /> JOB ADDRESS.-_]/ 7L S' cAl PERMIT SR* — <br /> LICENSED CONTRACTORS DECLATICK il:20� <br /> I hereby affirm that 1 yam iicensed under the provielons of Chapter 9(commencing with Section 7000)of ON sion <br /> 3 of the Susirim and Professiom Cotte and my license is in foil force and affect. <br /> License#:J4-S Z 717 EM- _, Expiration Date: <br /> Con tor, ILLI <br /> Signature: _z4tz�z Title. <br /> Pmnl no, iiewdetl <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm under perralty of perjury one of the fallowing deftnt oria: (CHECK ONE <br /> I haus and will meftin a mrf cn%of r»bnserrt to zelf•insum far worktm;'compe sation,as provided f x <br /> by section 3700 of the tabor Code,for the performance of the work for which this Dermit is issued. <br /> XI have and will rneinvAin worker's'compensation insuranm,as required by Section 3700 of the Lebor Cc ide, <br /> for 1ha performance of the mrk far which this permit is Issued. My workers'=mpanseticn insurance <br /> carrier and policy <br /> �numbers <br /> /are: <br /> Carrier: i�d /Y �/�' Policy Number... '.✓QJ r <br /> I certitij that in the performance of the worts for which this permit is issued, I shall riot employ any pemoi)in . <br /> any manner so as to beftOMa subject to the workers'compensation lawn of CNIfornia, and agree that if I <br /> shw4d uoorne subject to the workers'aomprxn=tion pmvisrdris of Seaton 3700 v the Lamar Code, 19 earl <br /> forthwft c'o pIy Ith those pfovisions, A <br /> Date: d Si oartur e: .� <br /> "nW Name, JOA/ I / <br /> WARNING:FAILURE TO SECURE VOPMR9'COMFEN3ATIO14 COVMAaF,IS UNLAWF rL,AND SHALL SUEJI ECT <br /> AN EVFLDYI!R 70 CRIMINAL PENALTIES AND CMI,FINES iJp 1.0 oNa iiuND tEo THOUSAND WLIARS <br /> l$7Q4,ROh.), <br /> IN ADI)fTrON TO T149 COST OF COMPENSATION.INTEREST,ATTORNRrs Fl:.E%,AND DAMA[i>*S.IS <br /> PROVIDED FOR IN SECTION SM OF TW r ABB 00r)F, <br /> A FiQRIZATI FCR TH THAN C-57 SIGNING PERMIT JkPPLICATION <br /> T, k Nig—ture nfC-67lienn0@4 dutharimd mprmiie"tati(o), <br /> herby authors(print name) <br /> to Sign this sen Joaqulq Courrgr WP.II permit Appiloarlinrr On tt't)r behalf, i underneand this a(uthorizatitm 1s yRltd f,r <br /> oft(1)y@ar and is!hotted to#m vwatk plan dated on the ftnt pa"of this application, <br /> 8-29.021 nit[ <br />