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10/172001 WFID 19:00 FAX <br />zooln [oeag ON Xa'Xzl o(=:zT aa,A Tata-,/sT/aa <br />�5. San Joaquin County EnAronment-al Hear11 th Services, Unit IV Well Permit APPII,ratfon SaPPIarnetlt <br />JQS ADDRESS; �11�, c9 PERMIT SR#,. - <br />LICENSr-D CONTRACTORS DECLARATION, '(LCA <br />1 hereby affirm that I urn liucriced under the prc+VisicrTs of Cri,4pter 9 (r:orrimencing with Sion 7DOQ) of DMSion <br />3 or tqe Business and Professlorvs Code and .z1y ilcenso Is In til force and effect. <br />License # -- - Expiration Data: <br />Date' Aa-lix i <br />1 &ignatirnEr_UXJLAI'4�Title: C <br />Printed name: <br />WORKERS' COt' PENSATION DECLARATION <br />i I hereby affirm under penany of perjury one of the Following declarat an3: (CHECK ALL THAT APPLY) <br />I ZI have and will maintain a cui lWitate of ccnsent tv self -Insure for workers CorrrReYsad❑n, zs rrovided for by <br />�i Sei:;�ion 37013 V the Lubdr Code, fortho pertgnrance of inorrrorK ter which this aermil. is issued. <br />iIi _ I have and wiii ttrairTtain Wcrkera' compensation insurance, as re;uired by Sr-❑tlon 9700 of iFe Labor Ccde, <br />for 11he performance of the work for wl rlch this pernut Is issued- My wl:rksrs' campe Isaticn irsurar7rra <br />rarrler acrd policy numfo� are- <br />CarrierF -i 1 Policy Number. <br />I certify that in the performance of we worKiorwh'ch this permlt 15 Issued, I Sr'QJ1 not emplpy any perzgn it <br />—any manner se as to become subject to the workers' compensation laws of Caiif❑mia- and 25nee that If 1 <br />1 Should become subject to tt-e workui s' ecrnpensatiaa pror+isionc of Sactian 00 of the Lacer Code, I shall <br />forthwith comply with those prnvininns <br />Date, 1 L) Signature' <br />.11 r <br />printed Name, <br />WARNING: FAILURE TO SECURE WORKERS* CoMPSN$AnON COVERAGE IS UNLAWFUL. AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PeNALTIES AND CIVIL FINES IJP TO ONE HUNDPFD T14OUSAND DOLLAF-3 <br />(5100,000.), IN ADDI'"ON TO THE COST OF couPENiAT1oN, Iiti WREST, ATTORNEY'S FEES. AND DAMAGES AS <br />PROFlOED FOR IN SECTION 3706 OF THE LABOR =)E, <br />( -"4(s <br />ignature ofC-57 licensed authorized reprc:mntative), <br />horoby2athor9�ea (print narno} TC_ t I�anLll Y <br />to Vgn this San Jaaquln County Well Perrn[t Applicatlon on my, behalf, I andrersta�ai trill authprizatYon i9 valid ter <br />ens 11) year and is limited to the work ALsn dated an tfic frwlt v%Io of 0-14 apptl+AtIOn. <br />S-17-20001111111 <br />of102 <br />Ed WdaI7.ET WOE r' -T 'I='0 �=HFlh HSS ME : -I-IN �hJl�A s1Sr'1'eL*J o-raG p_inoari : WQaA <br />