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FEB-26-2001 09:41 FROM:TWINING , INC. 559 268 7126 T0: 683433 <br /> P.003,005 <br /> %86=M b00:39tid 'DNI 'S JNINIMICOI £EbE89b60�1 Wybb:Bid Label-7d-tl� <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 31gs�1„s,;� s7/eX PERMIT SR#: 40 ?-!53B8 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business'and Professions Code and my license is in full force and effect. <br /> License#; S:f06Ae ExpirationDate: RG9)q5Zo/r <br /> Date: ;F690/ Contractor. / L(J/�/� A40-S <br /> Signature: � Title: (iV_ <br /> Printed name: ^/ • r /V7 z�/�Ar� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain 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 /> 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: ar <br /> Carrier:}22/25 �IIN� Policy Number: /Y$0097— <br /> $009 7" CD / <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 subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall <br /> forthwith <br /> comply with those provisions. <br /> Date: .��i (3d / Signature: ..�� ma <br /> Printed.Name:. ! 4r,*. z y/"yJ.e(_ <br /> WARNI NG:'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 /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, (C-5711censed authorized representative),hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> 5-17.20001 MI <br /> b0 39Vd 800-13 H1JId eeU689b60L Lb:80 T00L/9Z/L0 <br />