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05/15/2000 08:21 209468 FIFTH FLOOR • PAGE 03 <br /> San Jfla, uin�CounYt 'Environmental':: <br /> Nallalth Seru�ces; Unit IV Wepermit Appli�atio[t Su p:lement; <br /> ,JOB.:,ADDRESS:�, %Ke i.✓�rf� . i. 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 effect. <br /> License#: — 67Z- 6t -7 Expifation Date; 6 0 -7 <br /> Ez Contractor_ M l'(`� ��'�— - ���� ��_ LC7P— 1 <br /> Date: f� <br /> Signature: Title: f <br /> Printed name' > <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 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 /> 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: <br /> Carrier: <br /> t- e_.)(k (g�S GU- Policy Number: 6075 4, I - "_ 03 — <br /> _ <br /> I certify that in the performance of the work for which this permit is issued, l 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. <br /> Date: Signature: <br /> Printed Name: <br /> WARNING_FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT 1 <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> 1 <br /> ($100,000.), <br /> $100, <br /> PROVIDED ADDITION <br /> SECTIONo3THE COST OF 7QS OF THE LABOR COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> FOR <br /> I (C-57 licensed authorized representative), hereby <br /> authorize t <br /> TT <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one t1)year and is limited to the work plan dated on the front pa a of this ap licatian. <br />