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L <br /> San Joaquin County Envlronmental Health Services,Unit IV Well Permit Application SUPPIGment <br /> JOB ADDRESS: ?Z AF' ERMIT SR#-00 Z <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby amrTn that I am licensed udder 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 W._ G S 7 - (441-VI G —Expiration Date: 0! " �� • <br /> Date: Contractor <br /> Signature; X—A r a"rw 01 <br /> Title: <br /> Printed name: 1?� _ <br /> WORKERS' COMPENSATION DECI..ARATiON <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> Xhelve 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 i3scled. <br /> -9I 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 /> Camey: Qjd'CG / Policy Nlrmber• <br /> t certify that in the performance of the work for which this permit is issued. I shall not employ any person in <br /> arty ffwmw so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subpt to the workers'compensation provisions of Section 3700 of the tabor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: Q! -Signature- <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 19 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br /> (signature ofC-57 licensed authorized reprosentattve), <br /> hereby authorh*(print name)_ &Mr2 7 GZ .� <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> 5-17-20001 M1 <br /> z/L a6Ed `Bb:OI LO-se-6nv !eOSO ELS 5Z6 ! 'QUI `6uz�s9l 1� 6uzTTTua 66aJ0 :/g ;uaS <br />