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0 0 <br /> Mar-24-03 02:43pm From-URS Corporitlon 714667TI47 T-620 P CD2/0D2 F-610 <br /> San Joaquin County Environmental Health Services, Unit Iv Well Pormlt Application Supplement <br /> JOB ADDRESS: Z/&P6 F( 1?4n&k0 /eOL PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under 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#; f� Expiration Date:_1 /Ze r/O y <br /> Date: 5/z ontraclor.( t g-2&/Ae t <br /> Signature: Title:JV <br /> C]DIIEro/lis i /y�je„®. <br /> Printed name: _ C40 ze PanmJ^ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _1 have 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 workfor which this permit Is Issued, <br /> I have and will maintain workers'componsetion 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 aro: <br /> Carrier:G-9/" Policy Number: C5 Z � <br /> I Certify thel in the performance of the work for which this permit Is Issued, I shall not employ anyperson 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'camp ansation provisions of Section 37DO of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: "54if /03 Signature: —a%4& <br /> Printed Name: �ry�y�p/1Bp/' PsenP�- <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 7708 OF THE LABOR CODE. <br /> 1,� /n/,',w ar— (C-57 Ilconsed eutherlted representative),hereby <br /> authorize UP-5 carpo pl h OV/ <br /> to sign this San Joaquin County Wall Permit Application on my behalf, 1 understand thle authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front pace of this application. <br /> 5-17-2000 1 MI <br /> ,�n�c iArXAgH1 AH WdLt, :E EOOZ bZ NuW <br />