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San Joaquin Co �J �a�iro��I�atc4 C537rpPERMIT SR#unty Environmental Health S es,cUnit IV Well Permit AppNeatio pplement <br /> JOB ADDRE <br /> ` 062i�3 f b <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License# S q9 7 Expiration Date: <br /> Date: OS /o -oOJ//� 'Contractor: WLSSi <br /> Signature: r✓( (.t • !//r+ 7#Ic: �6 i o. rt Lr/jtr�it a�ri <br /> Printedd name rut tno {�• �d <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certMeate of consent to self-insure 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 /> 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 are: <br /> Carrier: 4 /,,JS Policy Number. ZZhr6V6?Z7`(f <br /> I certify that in the performance of the work for which this permit is issued, t shall not employ any person in <br /> any manner so as to become subject 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, 1 shall <br /> forthwith comply with those provisions_ <br /> Date. G J '< < L' _Signature, <br /> Printed Name' F urmw Ia J� <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJEC• <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ORIN SECTION ADDITION H COST <br /> T LABOR CODE. <br /> ON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED <br /> 1 � Gr.fry�.,o Ff• / Dlt--�� f� � �. _(C\-57 licensed authorized representative).hereby <br /> authorize_ T �'�'r ERZ <br /> to sign this Sari Joaquin County Well Permit Application on my behalf. 1 understand this authorization Is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> y17-20001 MI <br /> V1i-d 90 d 199-1 9d9z01z9z6+ 113MO1v0 1 M089-word wdol:60 i0-10-FEO <br />