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82/13/2001 08:36 2094683433 FIFTH FLUUK <br /> { San Joaquin County Environmental Health Services,Unit IV Well hermit Application 6itpplament <br /> JOB ADDRESS: IERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION &CD) <br /> IE <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 affect. <br /> License#: ct t5b Expiration Date: /0/21 <br /> f <br /> Date: p �✓7 Contrac „ -3 rev!z ! -S <br /> Signature, / Title: <br /> Printed name: <br /> r WORKERS'COMPENSATION DECLARATION <br /> j I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> i <br /> 1 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 Issuod. <br /> +� I have and will maintain worker'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. 2.OJ6 t' Policy Number: 40 0, <br /> I Certify that in the performance of the work for which this permit Is issued,t 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 <br /> forthwith comply with those provisions. <br /> Date-,7��l0l _signature. <br /> Printed Name: lcf -Q <br /> WARNING:FAiLURE`t'O SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYERTO CRIMINAL,PENALTIES AND CIVIL FINES EJP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADOrrION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR COM <br /> IC-5T licensed authoeized representative),hemby <br /> authorize h e <br /> to sign thLs San Joaquin County Well Permlt Ap ligation 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 /> s..17-2000 r MI <br /> i <br /> I <br />