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San Joaquin County Environmental Health Department Unit IV Well Permit Application Su,p— - IA <br />JOB ADDRESS._ G ram ; a 6 (Z �, �tY.c�,, PERMIT SR#;. <br />LICENSED CONTRACTORS DECLARATION I'L_9JD <br />I hereby affirm that I am licensed under the pravislons of Chapter 0 (commencing vilth Section 7000) of DN,slon <br />3 of the Business and Professions Code and my license is in full force and effect <br />liCgna81 P 7/;1,57 Emiration pate: <br />Drate: <br />Signature_ <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I keret y'affirm under penalty of perjury one of the following declarations: (CHECK, GINE) <br />I have and will maintain a czrtificate of consent to sdlfLinSure for workers' comwinsation, as provided f :r <br />by Sacticn 37017 of the Labor Code, for the pen°crmance of the work for which this Dermit is Issued, <br />i have and will maintain workers' ccmpQnsation insurance, as required by Sectlian 3700 of the Labor Cc de, <br />for the performance of the work forwhich this permit is issued. My workers' ccrnpwnsatien insurance <br />Carrier end policy numbers are <br />Carrier <br />Policy Number: <br />i c3r65i that in the perfcrmnnce of the work for which this permit is Issued. I shall not employ any persor in <br />any mariner so as to beGcarre subject to the workers' compensaticll IawS of Caliiar•ig, and ngr-e® that if', <br />should became sUbfea'to the workers' compensaticr, provisions of Se�ion 370 I o t Labor Code, I stall <br />i fcrthwith comply .,XKh those prcviSions. <br />TF=iration Date: 5ignatgre: �:� <br />PrintP,d Marne,— <br />`NARNiNG: FAILURE TO SECURE WOPKERS' COMPENSAT10N COVERAGE IS UNLAWFUL-, AND SHALL SUb ip P <br />AN EMPLOYER To CRIMINAL PENALTIES AND CIVIL FiNES UP TO ONE.14UNDRtAp THOWI;AND DOLLARS <br />($-00,000.), iN ADD17ION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FF i_S, AND DAMAGES A S <br />PROVIDED FOR IN SECTION 3708 OF THE LABOR COBE. <br />ADT RiZA N NER THAN C-57 SIGNING PERMIT APPLICATION <br />I, <br />lgipnature ofG-97licensed atihor,'zed representatIvc), <br />hereby authorise (print name) C 1A v k <br />W sign this San Joaquin County Well Permit Application an my bellalll•, i understand this authorization is valid fol <br />one (1) yOmlr arrd. IM ixMited to tno work plan dated on Me front page of thin application. <br />B,RU2 I MI <br />rM 20 -?2,001 <br />6MI04 <br />