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F�P.2?.26t7c E;:;�F'M APEX ENVIROTECH, INC. NO-325 P,C <br /> San Joaquin County Environmental Health Services, Unit IV Well PermItApPlieation Supplement <br /> JOB ADDRESS:_ IIQ� � / tyy� �yrrf PERMIT SR#:�z� l300 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby a(fimn that I am licensed under the provisions of Chapter 0 (commencing with Section 7000)of Dlv)sion <br /> 3 of the Business and Professions Code and my license is In full force and effect. / <br /> License#:_.11-:T9P1 ---__—Expiration Date:__ <br /> Data: 2 4;2, Contractor �/�/Q0�3 �iv_ ✓_ <br /> Signature: <br /> Title: <br /> Printed name: Dn/J SrGft t� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: f CHECK ALL THAT APPLY) <br /> _ I have and will mffintaln a certificate of consent to self-insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> V I have and will maintain workers' compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and Policy nru�mbenrs are: <br /> Carrier:^/�dw�- �j _ Policy Number: �/3 �� 731P3 <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'compensation laws of California, and agree that if I <br /> should become s4lect to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date• Ll?-O-2 Signature:✓ <br /> ValIYo X0//1 L Printed Name:_ D�i,!i ft h -B - 5 t Ll 6 D <br /> WARNING:FAILURE TO SECURE!WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED R IN SECTION 3706 OF THE LABOR CODE. <br /> 7700 (C-57 licensed autheriaed r/epresenfative),hereby <br /> authorize �ph Off` L' <br /> 9�1 <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization is valid for <br /> one(1)year and IS limited to the Work plan dated on the front page of thta application, <br /> 6.17-20001 M1"� <br /> rte, .,� c,sr 7asiC9i6 fi02Ja N3 Wd 69: LO a3M1-Z0—LZ-83d <br />