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an Joaquin County Environnental Health Sardcaz,knit)4 Wslt Psrntit A,Hplic tion Svppi®' er t <br /> LICENSED CONTRAC7CFtS DECLARATION <br /> I hereby affirm that I am ilaensed under the provisions of Chapter 9 (commencing with Secticn 7000)of Division <br /> 3 of the Business and ,Professions code and my license is in full force and effect, <br /> Llcsnao n �J7J <br /> 427 /Expiration Date: /o/� z D� <br /> Date; Contractor, <br /> Signature: }} / Title: <br /> Printed name: ma �JQ ` <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury 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 /> zSgeOon 3700 of the Labor Code, for the performance of the work for which this permit Is issued. <br /> _✓11 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. 1 I � 10.4e � Policy Number: r/V C, <br /> I certify that In the performance or 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 California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Cade, I shall <br /> forthwith comply with those provisions. <br /> Data: Signature. <br /> PrintedName: 0,2"4', <br /> � 4c) l4�y 2 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND 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 <br /> /LABOR CODE. <br /> (CST licensed authorized representative),hereby <br /> an}ttorha� <br /> to sign this San Joaquin county Well Permit Application on my behaff. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan,dated on the front papa of this application- <br /> 5-17-2000 f MI <br />