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SE—11-lUUI WE U�t�b YI"1 LHTPit Uhr1 IbILNi)LN UU rrth hU, JUJ ZIJU DUO( r, UL <br /> V71/LU/UL SVP LL:CO tA.\ LSV 91.-r10 <br /> San Joaquin County Environmental Health Services,Unit IV Well permit Application Supplement <br /> JOB ADMIESS: ND I�� iY1Al., 5ta��1-L r�_ �___ <br /> PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that l am licensed under Ir,e provisions of Chapter a(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in fuil force and effect. <br /> License 1v, S51 I Fzpiratron bate: 1900 ___...— <br /> Oatp: Contr3clor, <br /> Signatur 4q� Title: V7J\e406 <br /> Printed name:`t�Q <br /> WORKERS'COMPENSATION DF-CLAFZATION <br /> I hereby affirm under penally of prriury Weal the following declarations: (CHECK ALL THAT AT'PLY) <br /> I have and will maintain n certificate of consent to setf-+nsure for workers'compensation,as provided for ny <br /> lection 3700 of the Labor Coda,for the performance of the work for whim this permit Is issued. <br /> I have and will maintain worhem'compensation insurance,as required by Section 3700 of the Lobor Code, <br /> for the performance of the work for wKcn this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: f n 1 YJ c L, ' <br /> e15�h Policy Number,J1" l� a12--Y"�-- --- <br /> Carrier: -NoU�p,,.C�dt�l�""�' <br /> I cenify that in the performance of the work for which this perm tis Issued.1 shalt not e+nploy any person in <br /> any manner so"to beGOMC subject to Ine worxers'compensation laws of Calif0rni3•and aoree that if 1 <br /> should became subject to the workers'componsalion provisions of Section 3700 of rho IICc•dc,1 shad <br /> forthwith comply with those provisions. <br /> 0.. <br /> Date: 01 5ipnature. _ — <br /> Printed Name: o <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE HUNDRED THOUSAND DO.LARS 1 <br /> (S100,000.),IN ADD41loN TO THE COST OF COMPENSATION,INTEREST.Al I ORNEY'S FEES,ANO(.)A..M,^�GES AS <br /> PROVIDED FOR IN SECTION 3708 Of THE LABOR CODE. <br /> -57 lic4nsed authon:ed representauvc),hereby <br /> authorize <br /> to sign Ihf&San Joaquin County Well Permit,Application on my bahalf. I undersand this authori:0t _n+.vat d fur <br /> one(1)year and Jr limited to the work plan doted on the front page of this appttcation <br /> 5-17-20001 MI <br /> z-d *e8a Tea 139 ONI 303 TU O1 daS <br />