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t 1 <br /> 02/13/2001 08:36 209468343 . FIFTH FLOOR - PAGE 03,.,; <br /> r <br /> I <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affinn 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#: bZo b� nExpiration Dat/e: <br /> �7 �D i Contract 69 <br /> Date: / <br /> Signature: XdLl /Ap - Title: <br /> �9��C <br /> Printed name: �a-ld�—T <br /> WORKERS' COMPENSATIy�O}y{N DECLARATIONPit <br /> r`•. <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPL` ) . . <br /> 1 nave and will maintain a certificate of consent to self-insure for workers'compensation,as provided for by <br /> I <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> ✓ 1 have and will maintain workers'compensation 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 /> Carrier: Q.C 1C �C / l�7 t 2ir� Policy Number: !Q C 2 /570& ,5-&D <br /> i <br /> I certify that in the performance of the work for which this permit is issued. 1 shall not employ any person 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'compensation provisions of Sectio 00 of the Labor Code, I shall r <br /> forthwith comply with those provisions. <br /> Date: 7 q101 O/ signature <br /> Printed Name: <br /> / Yla rzL Gy� err e� <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 i <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS I <br /> PROVIDED FOR IN SECTIO <br /> N <br /> 3706 OF THE LABOR CODE, r <br /> 1, <br /> (C571icensed authorized representative),hereby <br /> authorize <br /> ,/7fC-t5 <br /> to sign NiisSan Joaquin County Well Permit Ap liration on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. _ <br /> 5.17-2000!MI _ <br /> i <br />