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TUL-02-2002 14:26 FROM:PRECISION SRMPLING 5102374575 TO:650 691 9837 P.2/3 <br /> 06/19/2002 14:29 209463 r>.r rn rLuum . .,..� �- <br /> San Joaquin County Environmental Health Services, Unit rV Weil Permit Application Supplement <br /> JOB ADDRESS: `'123 �- L i��C�� UU- 10)- PERMIT SR#.. <br /> LICENSED CONTRACTORS DECLARATION CD <br /> I hereby Win m that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of DivisforrC <br /> 3 of the Business and Professions Cade and my license Win full force and effect. <br /> License R: / A U <br /> Expiration Date: <br /> Date: 7 O t— Conlractor: J un /- <br /> Signature: Title' <br /> Printed na e• cr <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pejury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I 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 /> 1 have and will maintain workers'compensation Insurance,as required by Section 3704 of the Labor Code. <br /> for the performance of the work for which this permit is issued_ My workers' compensation insurance <br /> carrier and o1i y numbers are: G <br /> Carrier: �eg_�! ° ✓1�`!- i p Policy Number. 40C" rJ-7r QRZ--3 Oft <br /> _t 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 Califomle, 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 514ALL SUa11=CT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000,), IN ADDITION TO THE COST OF COMPENSATION.INTEREST,ATTORNEY's FEES,AND DAMAGE'S As <br /> PRO R IN SECTION 3706 OF THE LABOR CODE <br /> 1, e�A (algnaturre ofC.57 licensed authorized repmsentadi ), <br /> hereb uthorlte(print name) uy J /+t ig 61,0 fa;'TdLA 0 S1 W'y <br /> to sign this San Joaquin County Well permit Application on my behalf_ I understand this authorization is valld for <br /> one(1)year and Is limited to the work plan dated an the front page of this appllciatlory <br /> 577-2000 1 MR <br />