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i <br /> Ow <br /> 01/30/2004 FRI 15:17 FAX X1002 <br /> San Joaquin County Environ>Mentat Hie Ith SerynIt-IVices, WWelt Permit Application Supplement <br /> rn <br /> JOB ADDRESS:a PERI IT- SES#; <br /> LICENSED CONTRACTORS DECLARATION (LCD) I <br /> I hereby affirm that I am IICer1Sed under the provisions of Chapter D (commencing with Section 7000) of Division <br /> 3 of the Business and Piofessions Code and my license is In full force and effect. <br /> �7 <br /> License#: 0 -4/ Expiration Date: <br /> Date-' — <br /> C) C _Contractor;VA5,). <br /> � <br /> Signature: Title: <br /> Printed name:�J�GK1Ll_ 0 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of per)ury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent�Tto seefofthe work for which this permitan, as issued.rvided for by <br /> Section 3700.nf the labor Code, for the pe <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: _Policy Number: -(�l <br /> Carrier: <br /> V� �-t•�— <br /> I 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 California, and agree that if 1 <br /> should become subject to the workers'compensation provisions of Stion 3700 of the Labor Code, I shall <br /> forth w th comply with those provisions. i <br /> Date: ?� Signature, ---w <br /> Printed Name: ,.Ll�L <br /> WARNING:FAILURE TO SECURE WORKERSCOMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDREo THOUSAND DOLLARS <br /> 1N ADDITION 70 THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, <br /> (C-57 licensgd authorized repres ntaflve), hereby <br /> authorize <br /> to sign County Well San Joaquin CounWell Permit Application on my behalf. i understand this authorization is-valid fol <br /> one ti)year and is limited to the work plan dated on the front page of thlS 0 plication. <br /> —r0_. •��i <br /> .. . — • — <br /> RECEIVED TIME JAN, 30. 3 : 27PM • <br />