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• 8'l f�Uj2-'� moi/ •S _ <br /> �n Jonglaln County EnvironrnQn"Mf Heatth Department Uhl(IV Well chat ppli ition S plcnacrrrt <br /> JOB ADDRESS:-l � �(/� vLQ � PERMIT SR#: � <br /> o5S�5 G�, <br /> ' "/ —" *w-65✓. 15s.lcao� <br /> p�f'?CENSFD CONT RACT OPS DECLARATION (LEd�OY� <br /> I hwaabY taftm that l am Ii"rased under the pmvisirw,± of Chapter 9(nonamariew,g with Section 7000)of Division <br /> 3 efts' and Pn,fas.5�cwrs Cade a=vti na f 4r�n e Ig Ir.3tail firxr;o end et(Qct. <br /> ; LL <br /> LkdPrse .m,.-.. <br /> C1ate- l n+ .gi2nr <br /> Printed name � G fl--,- <br /> WORKERS' COMPENSATION DFCLAPATION <br /> t hereby affiaan unrJrrr penatty d perjurytcera aklNe to9av4ng uerdaatations. (CHECK ONE) i <br /> _I have arab will maintain a c*rttilcato of Consent to 504t sura for workers,Compensation,as provided for <br /> by Section 3700 of that Labor ,faf the performance at the we*tar which Mals taamift is issued, <br /> I <br /> I have and will maintain wockers'compensation in a ranw,as cequoW by Section 3710 of the Labor Coda, <br /> fe"etre Rr,f0wros"im Of the wank tw whkh this permit is Issued. MY"Bees`wrap MiDn Insurance <br /> i Carrier and Palley nurnb7!�: <br /> 'P '" „f LL <br /> Carrier; T <br /> �.� � � may Number: <br /> I catfl4y that in the pertomance of ft work for which this permitis issued,t shall not employ any person in <br /> any ni weer so as to beraoma,subject to the workers rxa Iva of Celffomaa,aef agree that if 1 <br /> should become subject to the workers'compensation provisions,of Saaction 3700 of ft Labor Coda,t shall <br /> kuthwith rvmply with those proviston s. <br /> r <br /> t"xpieatlarn tJatxr: Signatere:.�{� ��' .•`.� s a. i. <br /> f yy <br /> Printed Names + l 1 :`..� f .- L j •• 1`ct.9` t <br /> WARNING;FAILURE TO SECURE WORKERS'COMP€NSATiOH COVE IS U"LAWfZ.7AMID SHALL SUEPLUIP T <br /> AN ENPLDYE R TO CRIMINAL PENALTIES AHD CIVIL PINES UP TO OHE HUMORM 9°HOUIRAND DOLLARS <br /> 'p (ST( tI01.},IN ADDITION 10 1 HE COST OF COMPENSATION,INTEREST,AlIV40ara MS.AND DAMAGES AS <br /> ( PROVIDED FOR IN SECTION 17oc,OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> L.—...�..,,...�. s ...;.::� -`, rte/ fsignedsaresxfCv'`9 tt�fieaed sxrrhorirnd rti>aesantaNw�a�, <br /> haraby airthortrefprlrst.+rams' c(•.Ni S �,F1. 7?'l7 SCO <br /> to sign this San.Joaquin County Wait PonadR Application en Ary hahalf. t Understand Otte atahuriA ion is valid for <br /> orae t1I yeat And i*limited to the weak plan dated on the front psga at thls.Apitipzativn. <br /> 9-19-alai M1 <br /> FIID 2y�U2d6@I. <br />