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�, .. <br /> SECOR PAGE 03/03 <br /> 06/30/2004 09:05 9168610430 f� t <br /> `Filo <br /> San Joaquin County Environmental Health Department Unit IV Waff Permit Application supplement <br /> JOB ADDRESS � °� HERMIT 8R#: V3072 772 <br /> ® .sem o G-.�•,sladG� va->�-----S2�o 3g�2/ <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 Proffession$Code and my license Is in full force and effect. <br /> License#: 7/ZIV/es7 Expiration Date: <br /> Date: 6`30- eF/ Contractor: <br /> Signature: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent t0 self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the parformance of the work for which this permit is Issued. <br /> _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: /i <br /> Carrier: '2 % Policy Number: O4lH"7d77 <br /> 1 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 shell <br /> forthwith comply whh those provisions. <br /> Expiration Date:_lo-/-OC/ Signature;-- <br /> Printed <br /> ignature:--Printed Name: ABt— <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ADDITIONIN HE FTHE COST <br /> COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR SECTION <br /> AUTHORIZATION FOR OTHER THAN C•57 SIGNING PERMIT APPLICATION <br /> 1 � n�(signature ofC-97 licensed authorized representative), <br /> hereby authorize(pont name) 5 a <br /> to sign this San Joaquin County Well Permit Appli"llon on my behalf, I understand this authorization Is valid for <br /> one(t)year end Is limited to the work plan dated on the front page of this application. <br /> 1149-02/141 <br /> EHD 29.01-001 <br /> 9/30/2003 <br /> Z00 121 aurTIT.IO pJe"1300t 00£f6L£LOL SVd 9£:60 £OOZ/6Z/60 <br />