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12/07/2000 09:52 2094683433 FIFTH .FLOOR PAGE 83 <br /> r � <br /> San Joaquin County Environrneni2l Health Services,Unit N Well P®rmlt Application Supplernent <br /> JOS ADDRESS: <br /> 33PERMIT std#:Q� 7�' -2 21 <br /> LICENSED CONTRACTORS DECLARATION (00 <br /> I hereby affirm that I am licensed under the provisions of Chapter g(Commencing with Section 71304)of Division <br /> 3 of the Business and Professions Cade and my licen$6 is in full force and effect. <br /> License#: a a-s Expiration Date: <br /> Gate: t)a 0 5J0 j Contractor: 2A ov-af < <br /> Title: <br /> Signature: - ---_� - - — - - <br /> Printed narne• Cb(f r <br /> WORKERS' COMPENSATION DECLARA'T'ION <br /> I hereby affirm under penalty of perjury one of the following declarations- (CHECK ALL THAT APPLY) <br /> i*have and will maintain a Certitiicste of consent to self4nsure for workers'compensation,as provided for by <br /> Section 3740 of the Labor Code,for the performance of the work for which this permit is issued. <br /> I have and Will maintain workers'compensation insurance, as required by Section3700 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 /> Carrier. <br /> -Fe w Lsa S Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, 1 shaft not employ any person in <br /> any should become subject to the Sworkers comp ation provisubject to the workers' ions ation laws of California,and agree that if I <br /> manner so as tO bema anns of Section 3740 of the Labor 004e, ishall <br /> forthwith comply with those provisions- <br /> Date Signature, <br /> Printed Name- <br /> WARNING:FAlLURr=TO SECURE WORKERS`COMPENSATION/COVERAGE IS UNLAWFUL,AND SMALL SUBJECT <br /> THOUSAND DOLLARS <br /> AN EN[I�LCiYER Tf3tI'tIM11VAL pENALTIES AND CIVIL FINES Up TO CN Lz HUNpR> D _ . <br /> PROVIDED N A SECTION N TO 37 6 p COST <br /> OFt OMP SATIO V,INTt'ii1wST,ATTflt�NEY'S I:EI=S.AND t AIUTA S"As <br /> P <br /> I, IC47 licensed authorized representative),hereby <br /> auth orfse <br /> to sign this San Joaquin County Well Permit Application on my behalf l understand this autharlzation is valid for <br /> one(1)year and is UrMad to the work plan dated on the frornt page of this application- <br /> 6-17-2000!Ml <br /> . ,Sc, �� <br />