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F. . . <br /> Q002 <br /> JUN 14 2002 1 : 46PM HP LASERJET 3200 COR SF PAGE 83 <br /> 1 510 3 2568 FIFTH FLOOR <br /> 08/14/02 17RI 12Z20�F�1X co�yod: <br /> Son Joaquin County Environmental Health Department Unit IV Well permit Application Sup�Ypl®rgent <br /> Pio ,t i y PERMIT SR#: <br /> JOB ADDRESS: abw'�H Sb� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professlons Code and my license is in fun force and effect.License , <br /> Expiration Date: X1-3 11 d;� <br /> Date: <br /> Contr ctor, <br /> l!1 I I L') ( l 1 <br /> _.....__ Title: <br /> Signature: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 4nsure for <br /> ers'compensation,as p <br /> 1ect on 3700will <br /> of the maintain <br /> l abor Coe for or th performcate of consent tancef of the workf�orkwhich this permit is ss erdOvided for by <br /> 3 <br /> Z 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 numbers are: �4 3,306 a S <br /> Policy Number: T <br /> Carrier. S�� <br /> " I certify that In the performance of the work for which this permil Is Issued,I shall not employ any person In <br /> any manner so as to become subject to the workers'compensation laws of Califomia,and agree that if I <br /> should became subject to the workers°compen rovislons of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Data: �! c��dZ�- SLgnature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPeNSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLJ-ARS <br /> (610000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDE S CTION 3706 OF THE R CODE. <br /> 1, (signature ofC-57 licensed authorized representative), <br /> hereby autherizs(print <br /> to sign this San Joaquin County Well Permit Appllcatloo on my behalf, 1 understand this authorization is valid for <br /> one(f)year and is Limited to the work plan dated on the front page of this application. <br /> 1.2&021 MI <br />