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r <br /> C-2/13/2001 08:36 2094683433 FIFTH FLOOR � <br /> . PAGE- 03 <br /> San Joaquin County Environmental Health Services,Unit IV Wall <br /> Permit Application Supplement <br /> JOB ADDRESS: <br /> PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LLCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(Commencing with Sectlon 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License A 7 1? Expiration Date: __ 11 p Z,00 3 <br /> Date: 7 Contractor: <br /> Signature: Title:� rn�, • <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I ha+a 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 /> I 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 /> CafflerAwAiat4A Av6 N1 4WL.. J1. Policy Number., <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'cornpensetion laws of California,and agree that if I <br /> 4 should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> j Date: O1 Signature; <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSAT10k COVERAGE IS UNLAWFUL,AND$HALL 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 COMPENSA'T'ION.INTEREST,ATrORNEY'S FEES.AND 13AMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF Wig LABOR CODE. <br /> 10w7 licensed authorized representadve,hereby <br /> Y <br /> authorize V4t`k_1. <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization la valld for <br /> one(1)year and is limited to the work plan dated on thO front page of this application. <br /> &17.2000/Ml <br /> 1 <br />