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San Joaquin County Environmental Health Servicos,Unit IV Well Permit Applicatlon Supplement �~i <br /> JOB ADDRESS: �� � 4F-RMrr SRAI: P)D�/� <br /> ,.._._._w..,..r-9 <br /> LICENSED CONTRACTORS DECLARATION (LCO) � <br /> I hemby affirm that I am GcensW under the provisions of Chspter 9(commencing with Seatlon 7000)of Division <br /> 3 of the Business and Professions Code and my license Is in fall furca and effect <br /> t ration Date--- " Q <br /> Lic�anse#: .g: �-Z l�� �- lami .3 <br /> t rO..__ <br /> Date_ Contractor: /. <br /> Signature: Title: � J�4 CN <br /> Printed hauls: •` � <br /> WORKERS'COMPENSATION DECLARAMN <br /> i <br /> I hereby affirm under penalty of Pedury one of the following dedarabons: (CHECK ALL I'MAY APPLY} <br /> _I have arxi will maintain a certificate of consent to self-insure for workers'crmpans$tron,9s Provided for by 1 <br /> ! Section 3700 of the labor Code,for the performance of the work for which this permit is Issued. <br /> I have and will maintain workers'compensation insurance,as required bySeclion 3700 of the Labor Code, <br /> for the performance of the work for which this pwrnit is issued. My warkera'compensation insurance <br /> Corner and pQllcy numbers are• <br /> -UV <br /> Carrier-1 �_��. Policy Number-. s 1 <br /> d <br /> I certify that in the performance of the work for which tills permit is issued, 1 shalt not employ any parson in <br /> Ony manner so as to become SUDIe ct to Ute wOrKers'Compensation TOWS of California,and agree that if I <br /> should become subject to the wofkers'compensation ptovlsions Of Section 3700 of the Labor Code,t shalt <br /> forthwith comply with those provisions: <br /> Oate• Signature; <br /> Printed Name: i <br /> WARMING:FAILURE TO SECURE WORKERS-COMPENSATION COVERAQE 19 UNLAWFUL,AND$HALL SUBJECT <br /> AN EMPLOYER TO CRfMINAL pENALTICs AND CIVIL FINES UP Td ONS HtlNDRL THOUSAND DOLLARS <br /> ;t00,000.),IN ADDITION TQ THE COST OF COMPENSATION.INTEREST,AT TORNEi"s=EES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3106 OF THE LABOR CODE. <br /> Ed ',Md <br /> I+ Q� (.,7 licensed allthorl2ed repreSentativo),hem" <br /> authorize- w I Z}d La. vmrd <br /> to sign this San Joaquin County Wofl PermitAoNIC$tion an my behalf. I understairid thio euthofixatlon is xnlld fol <br /> one(1)year and Is►hatted to tfte work plan datod on tho front page of this app.lcation, <br /> 5.17,20001 Ml <br />