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FEB-26-2001 09:41 FROM:TWINING MS, INC. 5,59268 7126 TO 4683433 <br /> P.004/005 <br /> iB6=21 F06:391id 'ONI 'SSW JNTNSMICOI ££bE89b6po, idl 140717•tJn <br /> San Joaquin County Environmental Health Services, Unit IV Well Parrnit Application Supplement <br /> JOB ADDRESS: 3za-hGr,fo�,:A Sre.cr PERMIT SR#: DUZJ3E <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that l 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#n:/ C52> 1S:9 �Expiration Date!. eC� �0 <br /> Date: e 6A'o a/ Contractor: /� A" 4 AC <br /> Signature: .� Title: w <br /> Printed namJ�'11� 9 <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 /> 'thave 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: Q <br /> Carrier: Ski T F4AJiD Policy Number: _ /yBDO y7— D I <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 comply with those provisions. .�. OF <br /> Date;_42ir Signature: A <br /> Printed Name: &-_M.- WAX YAJ5 1{ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL`SU13JECT <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 3705 OF THE LABOR CODE. <br /> 1, (C-57 licensed authorized representative),hereby <br /> authorize <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 this application, <br /> 5-17.2000/MI <br /> EB 39vd 6001zi HJ.-41d EE4E89P60L 64:80 T00L/9L/L0 <br />