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12/19/2003 FRI 17:a�,_ ,+ <br /> San Joaquln County Environm0ntal eai{h SSe�rviycq,Unit IV WeU ParmitApp liaatron 546p{ament l <br /> PEPM1T. SR9' <br /> J013 ADDRESS: C 1 Clg <br /> W <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I nereby affirm that I am Ilcorsuc! under the provisions of Cin full o (e ndeff ing with Sector iUGO)of Div'rsron <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> Expiration Date: t��'�n/l�l� •_ <br /> � License M: I <br /> iq ontractor: et <br /> Dace. <br /> / Titlo: �o! <br /> Spnature: � ^� <br /> Pnnted narn <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury cne of the following declarations (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of corsent to self-insure for workers' compensation,as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work fur which this permit is issaed. <br /> e will maintain workers'compensation insurance, as -equired by 5eotion 3700 of the I rubor <br /> I naw:conCad- f <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: <br /> i l Policy Number. <br /> I <br /> I certify that in the performance of the work for which this permit is issued, I sha;l not employ any Person 'n l <br /> any manner so as to become sutg9ct to the workers' compensation laws of California, and agree that it 1 <br /> should become subject to the workers' compensation provisions of Se,4000 3700 cf ttie Labor Code. 1 shalt <br /> forthw!th conpi with those provisions. <br /> 'Zi Signature: <br /> Date, <br /> 1 Printed Name: I <br /> WARNING!FAILURE TO SECURE WORKERS'COMPENSATION COVERAGES UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($t D0,0D0.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED <br /> FOR IN SECTION 3Te6 OF THE LABOR CODE- <br /> jC-Z7 licensed' uthor" d rePrecentaGve), hereby <br /> f authcrlia '� wf� I <br /> to sign this San Joaquin County Well Penult Application on my behalf. 1 undarsta this authorization 4s valid for <br /> ono t)year and ro IlmKad to rhe work p!n; dated on the front page of this eDp!ication. <br />