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05/01 '02 11:13 ID:CTENDIDO FAX:760-746-9� PAGE 2 <br /> d92 09:48 20946A- 18 AGE STOCKTON PAGE 93/93 <br /> I <br /> FILE <br /> San Joaquin County Environmental Health Department Unit N Well Permlt Application Supplement <br /> JOB ADDRESS.—' V(?-Zg / 1� PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONLL-CD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Divlslon <br /> 3 of the Business and Professions Code and my license to in full force and effect. <br /> License 7 C�i Expit itlon Date: D, <br /> Date: Contractor: <br /> Signature. Title._.. <br /> Printed name ,. <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaration& (CHECK ALL THAT APPLY) <br /> I have and will maintain a CeRlficate 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 /> I have and will maintain workers'compensatlon 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 /> Carder: "�` , /�^ Polley Number: <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'compensatlon laws of California, 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 lS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL,PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND 0OLLAR9 <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE, <br /> (slgnatur•ofC•97 licensed authortzed representetive), <br /> hereby authorize(Print name) <br /> to sign this Sen Joaquin County Well permit Application on my behalf. I underotand this authorization is valid for <br /> one (1)year end Is limited to the work plan doted on the front page of this application, <br /> �•sa.os�MI <br />