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SEP 24 2003 3: 01PM HP LRSERJET 3200 p• 2 <br /> SEP-24-03 WED 02:00 PK SACC - ",RAMENTO FAX NO, 916 974 8F R 02 <br /> `"✓ IN0011 <br /> POKbc) 17s5 W , I l'f` <br /> San Joaquin County Environmental Health Department Urr�k'tt IV Well Permit Application SUplentent <br /> act a. co �01 <br /> JOB ADDRESS: PERMIT SRO:_:3591 k <br /> LICENSED CONTRACTORS DECLARATIONLc coy <br /> 1 hereby alfirm that I am licensed under the.provitions of.Chapter 9(commencing with Section 7000)of Division. <br /> 3 of the Business and Prafasatons Code and my license is in full force and effect <br /> License 11: t SZ .��� Expiration Date:_ 6&,e _O Li'l <br /> gate: 1wr Contractor. ���. �%��lri+�► g �i�1'7iisr <br /> signature: �p Title: Jrili»S'/�iM�i�! <br /> Printed jfia�al- <br /> IF- <br /> WORKERS'COMPENSATIONPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> —I hero and will maintain a certificate of consent to sW4nsure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. <br /> have and wtq maintain workers'compensation insurance,as required by Section 3700 of the Labor Code. <br /> for the peAormsnce of the worts for which this permit is issued. My worters'compensation insurance <br /> carrbr and poky numbers are: <br /> Carrier.4�M Policy Number:r <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 became subject to the workers'compensation I"$of Calfomts,and agree that 91 <br /> should become subject to the worker.'compensation provisions of Section 3700 of the Labor Code,l shall <br /> fordwhkhh comply with those provisions. <br /> Date: [ �3 signature: <br /> Printed Name: <br /> WARMNG:FAILURE TO SECURE WORKERW COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> tPROYM[-0�IN FOR IN is TO THE COST OF ON 3700 OF THE LABOR COMPENSATION, <br /> INTEREST,ATTORNEY'S FEES,AND DAMAGES As <br /> AUTHORIZATION FOR O�THE,W THAN C-57 SIGNING PERMIT APPLICATION <br /> I� &age (elenoture ofC37 Nsensed authorized represented"?, <br /> hereby wthetise(print name` <br /> to sign this San ion"County Well Permit Application on my behalf. 1 understand this authorizedon is valld for <br /> one Iii year and is IirnRed to the work plan dated on the from page of this appitoatton. <br /> t•ZfOZ <br /> 1 MI <br />