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FROM West Hazmat FAX NO. : 191663EB613 <br /> 03i 09/0° May. 10 2002 06:45AM P1 <br /> � T71i.1 ]ff:5t� FAX I �yfii 0.190 • <br /> SEI:Uk-S�tCfll'1NTO <br /> Vinn2 <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: � 5/gLCTi7�{/ PERMIT SR#:__ <br /> 16 <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Socliun 7000) of Division <br /> 3 of the Business and Professions Code and my licence is in full force and effect. <br /> I.irense#: SS y`/ _ _—.- —Expiratiun Date: <br /> Date _...OS '/d "o Contractor: ` l_ e5 <br /> - <br /> Signature(—,�- —_.... _ —Tltle."� e3ro✓4L- <br /> �iiJ,rN�f6t9Z <br /> Printed name__ r G,L/p10 <br /> WORKERS' COMPENSATION DECLARATION <br /> I horoby affirm under penalty of per jury one of the following declarations: (CHECK ALL THAT APPLY) <br /> hava and will maintain a cortihcate of consent to salt-ins;ul'9 for workers'compensation, as provided for by <br /> vection 3700 n(tho I abor Code, for rhe pertnnnarwo of die work for which this permit is issued. <br /> I have and will maintain workers'compensation insuranra, as required by Section 3700 of the Labor Codr., <br /> for the performanco of flim work for which this permit it;issued. My workers'compensation insurance <br /> carrier and poly nurribars are: <br /> Carrier: i9�1/f Gico /� f _ Policy Number: ._ZZ-.J4✓612-7`/ I <br /> I certify that in the performance of the work for which this permit is issued. I shall not employ any paruun in <br /> any manner so as to bocome subject to the workers'compensation laws ut Califnrnia, and atgwo that if I <br /> should becunio subject to the workors'Cunipensation provision.;of Soution 9700 of the Labor Code, I shall <br /> forthwitn comply with thosa provisions. <br /> Date: O S �I d Z Signature: <br /> Printed Name: -=, Czt'r"� /t• ,�.ez�ny 1�� <br /> WARNING: FAILURE TO SECURE WORKCRE'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FIN=—UFTO'ONE HUNDRED TI IOUSAND DOLLARS <br /> ($100,000.),IN ADDI TION TO THE COST OF COMI�,VNSATION,INTEREST, AT tORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LA 0it COOS. <br /> • .. _-_ �.. __._�...'__ (siynatura ofc•57 licensed authorized representative), <br /> hereby mdhorizu(print name),.... <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and IG liinaed to the work plan dated on the front page of this application- <br /> _L-17.2000/Ml MI <br />