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e2/13/2001 98:36 2094683433 FIFTH FLOOR PAGE 03 <br /> San Joaquin County Environmental Health Services,Unit IV Well Kermit Application Supplement <br /> JOB ADDRESS: � o a PaRMIT SR#: <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* a`5'7 S_117-I&F F?' ,_,_Expiration Date: 4130&Z605 <br /> Date: Contractor: S 4(4rimq EX JOD <br /> Signature: Title: <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 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'enmpensatlnn Insurance <br /> carrier and policy numbers are: <br /> Carrier: ,� Av6 -t' ki.. J1. Policy Number: 5156 a35"Z 6800' <br /> f 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, hshall <br /> forthwith comply with those provisions. <br /> Date: Lo 1 O'k Signature: <br /> Printed Name: a INr 1ah, <br /> WARNING:FAILURE YO$EOURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENIAL nEs AND CIVIL FINl=$UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (x10,000.).IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNErS FEES,AND t]AMAG€S AS <br /> PROV10ED FOR IN SECTION 3706 OF THE LA13OR CODE. <br /> ("7 licensed authorized representative),hereby <br /> authorizeto sign this-tan Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and is Ilmited to the work plan dated on the front page of this opplication., <br /> 6-17-20001 Ml <br /> i ' <br />