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10/21/2004 THU 07:34 FAX lam <br /> r <br /> 12/2r,/700z' 00: 39 416861P,4aE I:121lid <br /> Sin Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESs: 73o C. 6--40s�� J��c� PERMIT SR#: <br /> LICENSFD CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chopter 9 (Commencing with Section 7000) of Division <br /> 3 of the Business and Profess. n& Code and my license a; in full force and ffect. <br /> License : .� O t! v Exp anon pate: 0 <br /> Datc: 111 115d Contra tor_ <br /> Signature: / f <br /> ,r Title; <br /> Printed rtarne: F y <br /> WORKERV COMPENSATI 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 to self-insure for workers' compensation, as provided for <br /> by Section 3700 of tho Labor Code, for the performance of the work for which this permit is lusued. <br /> I have and will maintain workers' componsation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work forwhich this permit is issued. My workers'compensation insurance <br /> carrier anApolicy nurnbe are: <br /> Carrier: t, ' Policy Number: <br /> 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 worker:.' compensation laws of California, and agroe that if l <br /> should become subject to the workers' compensa ion provisions of Section 3700 of the Labor Code, f shalt <br /> forthwi Comply lth those provhdons_ <br /> Date: f L� � Signature: <br /> n <br /> Printod Name: <br /> WARNING, FAIL-URE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,A A 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 /> //THORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> � <br /> J, I natuL;t- 67 licensed ahereby authorize (print name) ) � � <br /> to sign this San Joaquin County Wim Parfait Appllcatlon oil my behalf. I understand this rtuthorizatlon is vAild for <br /> one(1)year and 14 limited to the work plan dated on the front page of this appiicatloh, <br /> MI <br /> RFCFIVFD TIMF 0C.T. 7I P- 47AM 12/20 200.1 1.1.1 014 25 ITL/RJB NO 522,11 9.)002 , <br />