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San Joaquin County Environmental Health rviees, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:7SW.Vo4Pico , rr-a-e L CA `i -376 PERMIT SR#: eo Z4 3� I <br /> LICENSED CONTRACTORS DECLARATION (LCO) <br /> 1 hereby affirm that 1 am licensed under the provisions of Chapter 2 (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#= 5 S-Y`f ?5 Expiration Date: o/- 3/ 6 3 <br /> Date: 0S - G) "�r Contractor_ �[iS i � A2-r�n i n cc. �L "•�✓ <br /> Signature: Title: ��'�!o" n2 l4,•t-NA-6L'12 <br /> Printad nam cr+✓NLo Z.��" <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 certificate 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 /> 1 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, /Z-i L 04-0 Policy Number: Z 7 " '�f'P2-7 q <br /> i <br /> certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation taws 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- 0 S " `''7 �' i Signature- <br /> Printed Name: � X�c.ttvin7 ` L� <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE Is UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL EINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> J <br /> C, C-57 licensed authorized representative).hereby <br /> authorizar�fc2 ��tJBc�tE vt� /Sz;i i7rd �toi ZlL <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization is valid for <br /> one (i)year and is limited to the work plan dated on the front page of this application. <br /> 5-17-21)(30 1 MI <br /> V21-d VO d 259-1 9Z5ZOlZ5Z8+ 113MO1V7 R NM0ds-woad wdOV E0 10-10-AEH <br />