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HF'R-26-2004 14:39 FROM:ENPROB 5305892230 T0: 12099480621 P.2 <br /> u�i cul cuvt �.. .ct rn� cua aYu� • ..... ...,.. <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I 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 effe <br /> License#7. Expiration Date: <br /> Date: `� ontractor: .y QQ.OQ� <br /> Signature: _ Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> t have and will maintain a certificate of consent to self-Insure 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 /> 4—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 numbersare: -7 <br /> Carrier: -1 UA, Policy Number:��T 63260_3 <br /> __ <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'compensatio revisions of Section 3700 of the Labor Code, I shall <br /> forthwith com with t se provisions. <br /> J <br /> Date: Signature- <br /> Printed Name: <br /> f <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 /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN 5ECTION 3706 OF THE LABOR CODE. <br /> A -RI ZA ION OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. (signature ofC-57 licensed authorized representative), <br /> hereby authorize (print name) tan <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 /> 8-29-021 MI <br /> 04/26/2004 MON 15:39 [TX/RX NO 99491 2002 <br />