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0_/13/2001 08:36 20946834^'; FIFTH FLOOR !`:; PAGE 03 <br /> v � <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: Vlw Zi � 0 Uiay 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 eff <br /> ect. <br /> License#: ��5 7 S (2I&I? Expiration Date: 71,30 200 3 <br /> Date: Contractor: SpGdtlµyt <br /> Signature: J441 <br /> Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION, i <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I 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 work for which this permit is issued_ <br /> 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 <br /> are: <br /> Carrier: Aft► .r1U�.+� A061%� [KI. 6). Policy Number. 3B6D35� 5800 <br /> I certify that in the performance of the work for which this permit is issued. I 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 Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: -7 I,e 0% Signature: A" alnA <br /> Printed Name: <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 3706 OF THE LABOR CODE. <br /> j <br /> I, J lM ��'f tPl'Ce. (C-57 licensed authorized representative),hereby <br /> authorize -V—e-ItAt' S klf-FITS <br /> to sign this San Joaquin CountyWell Permit Application on my behalf. I understand this authorization is valid for <br /> one'(1)year and is limited to the work plan dated an the front page of this application. <br /> 5-17-2000 1 MI <br />