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02/13/2001 08:36 2094683433 FIFTH FLOOR PAGE 03 <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: ¢ eL h-? r PERMIT SR#: f <br /> I <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 effect. <br /> License pilo ZD7 Expiration Date: // /Ez3,7 0' <br /> 7 <br /> Date: /�g/e)/ Contractor: <br /> Signature: /)�2Z44,4 / Title: X-��. <br /> Punted name: /�C�L1l�e✓� <br /> WORKERS' COMPENSATION DECLARATION <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 are: <br /> Carrier:_l�(a �%C / LtC� Policy Number. <br /> 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 Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. „ <br /> Date: ��n/G/ Signature:— <br /> Printed Name: 1170m <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 /> (C-57 licensed authorized representative),hereby <br /> authorize f'd1 keel �/Y7 41-41 <br /> to sign this San Joaquin County Well Permit Applioa n 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 /> 5-17,20001 MI <br /> I <br /> i <br />