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San Jesquin County Environmental Hoeft Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 000 5 71 KL5 iov/RôeI PERMIT SR#: (90 3 VZ-5 <br />LICENSED CONTRACTORS DECLARATION (.CD) <br />I hereby affirm that i arr ileenied under the provisions of Chapter 9 (comManoing with Slat*, 7000) of Division <br />3 Of the Business end Pr10111BSIOnB Cage [ma my license Is In MI force enO rano , <br /> <br />''.77 7 00 7 Expination Date: <br />/ can ado , , E. , i pa.ch .6"4/4-V 7t/171rCikk4i/A,Pe1/41 Date <br />Signet/re: A r , .. Tltie rktjAlICIZ. <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm uncier penalty of perjury one of the following deoleretions; (CHECK ONE) <br />.4 heVe enrd will maintain a cart/cicala of consent PO 4elf-lneure for workers compensation, es provided for <br />oy Section 3700 of the Labor Code, far the performance of the work for which this permit la Issued, <br />I hive end will maintein WOncere l compensation Insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit le lasuen. My workers' cornpaneetion lhouranoa <br />carrier end policy numbeni ere: <br />Cerrlim,5 iqiNdr Polley Number: 7/3 - 73tc.; <br />I unit? that in the performance of the work for which this permll Is Issued, I shall not employ any parson In <br />any manner so as to become subject to the woriuri campenentlon laws of California, and agree that If <br />should become aubiasot to the wortcers' crompensatlo provIelons of Section 3700 of the Let5or Cette,I shall <br />forthwith comply with those provisions. <br />r <br />Ostia: / Signature: <br />/0//04 POMO Name: -120,1 /I <br />ir <br />WARNING: FAILURE To SECURE WORKERS' ComPENSAT1ON COVERAGE 18 UNLAWFUL, AND SHALL 8UllacT <br />AN EMPLOYER TO CRIMINAL PENAL.TrE5 AMP MIL FINE& UP TO ONE HUNDRED THOUSAND DOLLARS <br />e,c00.). IN AIDDITtoN TO THE Coin OF COMPENSATION, INTEREST, ATTORNEY'S MS, AND ootAaes A3 <br />ovIDEo FOR IN SECTION MS OF THE LAMOR CODE <br />AU OR T1ON FOR OMER THAN C-87 SIGNING PERMIT APPLICATION <br />License <br />hereby iuthorite (print name) <br />to sign this Ran Joaquin County WellPermtt App1IiUer, on my behalf. I underetend this eu-thorltatIon le veNd for <br />one (1) pig, and detect on the !rent pep of this application. <br />0-19-02 <br />(signature orC-57 licensed authorine representative), <br />s-J7 3 -),0 •tre