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a an JoagUift County <br /> S Er1VIri0nmentat Health5enrlces, Unit tv well Permit Appiketion supplement ) <br /> JoAaaRess: 2.ot� N• CJ ek RMIT SR#:_„ <br /> t <br /> f 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 Susiness an''d7Pmfessions Code anon my license is In"I force ar'4 effect. J� <br /> License*- C- L 7177! O Expiration Date: <br /> Date; y1J 041 actor S C a( <br /> Signature, _YttJe: � u�A <br /> Printed name: P✓f�, �� aF rt <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm urder penisity of pet;ury one of the following deetIMM Orin: (CHECX ALL THAT APPLY) <br /> I have and will maintain a cartffieate of=rsent to self-insure for workero'compem3s ion,tis provided�x by t <br /> Stiction 3700 of'Jta Labor Code. for the performance of the work for whictl this permit 18 issued. <br /> I have and will .maintain workers' compensation insura y Section 3700 of the Labor Code, ; <br /> `or t!-e performanca of.he work for whet.-)tris ptrmit is i"ued. My workers'compensation insumnos <br /> csrriBr and/policy numbers are: <br /> /� ' 1 n <br /> / Policy Number. � � <br /> _I certify that in tt-e oer`nrma!1c8 0`the work for whit`~ this permit is issued, I shah not employ any person in <br /> any manner sc as to tecorne subject to the workers'comgensabon (awe of California, and a4,ree that 9 I I <br /> should became sub)ect to the workers'compensation provisio SBCti 3 7 0U 0f the(.shoe Gode, 19haf1 <br /> 1 <br /> fonh�unth co l/mply with those provisions. <br /> f <br /> Data: —3 — 0 Signature: ! <br /> Printed Name: <br /> WARNING: FAILURE'O SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND$HALL.SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($Iag,000.),IN ADDITION TO T"F COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF T E-LABOR CODE. <br /> 1 r (C-57 licensed author lied..presentative),hereby <br /> authorize _��_ —� !/ 77C. -- -----' <br /> W sign We San Joaquin County well Permlt Appllcstlen on my behalf- I understand this authorisation Is valid for <br /> one(t)ye■r and is timit.d to the worts plan dated on the front pavo of this 40011CaU011i. <br /> s-11-20001 Ml <br />