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FROM ♦ West Hazmat FAX NO. : 191663613613 Mar. 04 2002 01:34PM P3 <br /> 03/04/,q; _MON 11:27 FAX 1 91801 (1730 SECOR SACRAMLN1.0 • 1?1002 <br /> San Joaquin County Environmental Ilealth Services, Unit IV Well Perrnit Application Supplement <br /> JOB ADDRESS: <br /> ..........-.--_ PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby aftirm that I am licensed under the provisions of Chapter!) (commencing with Section 7000)of Division <br /> 3 of Iho Business and Profession,; Corte and my lianmio is in frill forua and effool. <br /> Licenso )Y -,- S,Y9 7'I Expiration/Date: 0 / -3 /-03 <br /> Date: 03'o y/'0 7: Contrar r: t -/ 1�2rt�t j �,x�c,ca .t� co?it'd <br /> Slrgnetur .�ZX Ct - _ Title:' EXioNxt_ ��fix+ t,ti1— <br /> Print nal� _C..+.b1.e o/tt`4 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of porjury unn nl thn following dnrlarations: (CHECK ALL THAT APPLY) <br /> _I have and will rnalntain a oertificato of consent to soli-insure for workers' eomponsation, as provided for by <br /> Seolion VOO of the Labor Code, far the performance of the work for which this permit is issued. <br /> �I have and will maintain worker; umprnsation insurance, as required by Section 3700 of the Labor Gcxlo, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> rarnnr rind policy numbers are: <br /> Carrier: _�ifrt i Forte `^' S Policy Number: 2 2 P 'a✓G T 2 P y I <br /> ✓ I certity that in tho perfarmrance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to bOCOme subject to the workers'compensation laws of Cnlifomia, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labiir Code, I shall <br /> forthwith comply with lhuse provisions. <br /> Date: 03 °y . 6_L----Signature: .- -- v <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 19 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIM)NAt.I'FNAI:IIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION ItO THE COST OF COMPENSATION,INTEREST, ATTORNFY'S FFFS,ANI) DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> r,,_........,._.J.(s(gnatureofC-57licensed authorized representative), <br /> hembyauthorize(print name)_. J1 �'!Ss y J�GC�,$o ..S of -ECpq j! IIS TVIJJI!jL.1 <br /> to sign this San Joaquin County Well Permit Application on my hehall. I undarstand this authorization Is valid for <br /> one(1)year and Is limited to the work plan datrd an the front page of this application. <br /> s•17-26001 MI <br />