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)Z <br /> 0 6J AtW 3 � `7 �,uv <br /> San Joaquin County environmental Health Department Unit IV Wel)Permit Appliestion Supplemp nt <br /> JOB ADDRESS: 2-&4 GCJ( PERMIT SR*A_ 7/7-�o � ... <br /> 22�i �'< 2,i <br /> LICENSED CONTRACTORS DECD ION i;�� <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Div cion <br /> 3 of the Susiness and Professions Cade end my license is in full Torre And of ect. <br /> LiCense#: 145 7 7f751A expiration fate: 3/ . <br /> Date, 3 O Czl"T <br /> , �1,� <br /> Signature: / Title: <br /> Printetl nam7: _ � <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of Rdr7tary one of the fallowing declamtlonc: (CHECK ONE) <br /> I have and will maintain a cortirl'imme,of contSnt to self-insure far iwrkem'compensation.as provided t�r <br /> by Section 3700 of the Labor Code,far thra performance of the work for wh"C this permit is issued. <br /> :_4 I hnvo and will moinmin workers'compensation insurance, as required by Section 3700 of'he Labor Goch, <br /> for the performance of the work for which this permit is Issued. My workers'camp ensation insurance <br /> canter and <br /> �i i�cy�+n,�um'bens/are: <br /> carrier: 4jg Y - � �:✓� /� _�,_. <br /> i Policy Number: <br /> I cartirj'hat in the performanoo of the work,for which this permit is issued, I shall rot employ Argy person in . <br /> any manner se as to b�eomp swbject to the workers'compensation lawn of California, and agree that if I <br /> should Lecome subiect to the workers'compensation provisions of Soction 3700 a`the labor Cade, I s fall <br /> fortf;wftply Ith these provisions, <br /> co <br /> Gate: �+' D <br /> Signature:--A <br /> P6rtted Name: <br /> WARNING:FAILURE TO SECURF-!WORKERS,COMPENSATION COVEtZAGE IS UNLAWF;,,IL,AND SHALL SUJl.'rT <br /> AN EMPLOYi;R To CRIMINA4 PENAL-HES AND CiVI4 FINES UP To ONE HUNDRED THOLISAN13 004LARS <br /> RS4llOrA06-) IN AiJUIT10N TO THE COST OF COMPENSATION,INTEREST,AT-tORNEy's FI-E`r,ANtJ DAMAGES,t5 <br /> PMMED FOR IN SECTION 274E of T4fE LABOR COQaE <br /> f A 1-10RiZATT I FC7R TM_ TFIAIrI C,57 SIGNING PrRMiT' APPLICATION <br /> {signature o -67licRn,"-d Authorized repre_setytaryV(ji, <br /> hereby authorize(protist name) ��j <br /> to sign this San Joaquin County Well permit Appltoat;on on Briar behalf. 1 undern(:and thli'ization is valid f,)r <br /> (Inc('i)year and is limited to the work plan dated on the ROW Page of this,applicalfon. <br /> ��� ///-7 Z! <br />