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SEP 24 2003 3: 01PM HP .-LASERJET 3200 P• 2 <br /> SEP-24-03 WED 0200 Pit SAIC Nftw.")CRAMENTO _ FAX 10, 916 974 FN-0011 P. 02 <br /> �o�Do P��P 17ss <br /> u) , rl�' <br /> San Joaquin County Environmental Health Department r)it IV Well Permit Appiicabo3Supplem ant <br /> JOB ADDRESS: `.PERMIT SR#_ <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm ttwt I am ikmnu under the provisions of.Chapter 9(commencing with Section 7000)of Division. <br /> 3 of the Business end Profv eskms Cade and my license is in full forte and effect. <br /> License ly: CST �- - --Expiration Date: <br /> Qate: Lac. Contactor. 7 <br /> 9lgnature: Title: <br /> Printed name: (err <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and wiN maintain a csrtif►cate of consent to seif lnsura for w adders'eofnpens6on,as provided for <br /> by Sedlon 3100 of the Labor Code,for the performance of the work for which this Permit Is Issued- <br /> have and will maintain works s'compensation insurance,as required by Section 3700 of the Labor Code. <br /> •for the performance of the wort;for whist;this permit Is Issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Cornier. Policy Number:is lee <br /> I Certify that in the performance of the work for which this permit Is issued,I shall not employ any Person In <br /> any manner so as to become subject to the workers'compenestian IBM of California,and agree that 91 <br /> should become subbd to the worikers'compensation provisions of Section 3700 of the Labor Code,I shall <br /> forts with comply wRh those provisions. <br /> Date- l03 slpmature: <br /> a92 <br /> Printed Name' a <br /> WARNING:FAJLURE TO SECURE WORKERWCOMPENSATION COVERAGE IS UNLAWFUL.AND SNALLSUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE 14UNORP-0 THOUSAND DOU ARS <br /> I;tee,Va 1.).IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAOE3A3 <br /> PROVfDED FOR IN SECTION 3704 OF THE LARORCODE- <br /> AUTHORIZATION FOR OTNER THAN C-57 SIGNING PERMIT APPLICATION <br /> (slOnoture ax 47 Naensed authorized rePresentattw), <br /> hereby amomflze(print name) <br /> to sign this Sen Jog"County Well Permit Application an my behalf. I understand this autherizad"Is valid for <br /> qua(1)year and is Brasted to the wank pian dated on"from page of We epprtoatlon. <br /> 2.21.021 MI <br />