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02/13/2001 08:36 2094683433 FIFTH FLOOR PAGE 03 " <br /> i <br /> Ban Joaquin County Environmental Health Services,Unit IV Well Permit Appiioation Supplement <br /> JOB ADDRESS: 6ERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of tha Business and Professions Code and my license is in full force and effect. <br /> License <br /> Ce�� o� _ b �� � <br /> ' #: - --___--- .._Expiration Dat//e: 7— <br /> _ � � _-� -- ,..._.,_.` <br /> Date, D Pel Contrac <br /> Signature: - Title: HA f o <br /> Printed name: o( <br /> WORKERS'COMPENSATION DECLARATION <br /> hereby affirm tinder penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 'i nave 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 /> ✓ <br /> /1have and will maintain workers'compensation insurance, as required by Section 3700-of the Labor Code, <br /> for the performance of the work fpr which-this permit Is Issued. My workers'compensation Insurance <br /> carrier and policy numbers are: <br /> r fJ <br /> Carrier: lLC16 iff 1 Policy Number: ZA)C i S4 Co SZo D <br /> 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 Callfomia,and agree that V I <br /> should become subject to the workers'compensation provisions of Sectio 00 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: 7��/D� Signature- <br /> Printed Name: <br /> WARNINQ FAILURE fO SECURE WORKERS'COMPFNswrION COVERAGE Is UNLAWFUL,AND$HALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL,PENALTIES AND CIVIL FINE$IJP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($104.000.),IN ADDITION TQ THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,ANn IIAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> (C-67 licensed authorized representative),hereby <br /> authorize Cir cYl /.� <br /> to sign this.San Joaquin County Well Permit Ap lication on my behalf. I understand this authorization Is valid for <br /> one(1)year and is limited to the work pian dated on the front page of this application. <br /> 19-17-2000!MI <br />