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51237 4574 _ N0,523 P.2 <br /> DEC, 18.2003 12 37PM <br /> �( D`� v`l F1ru ofuT ST <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Appiieatlort supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION I.CD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 8 (commencing with Section 7100)of Division <br /> 3 of tho Business and Professions Code and my license is in full force and/Jeffect. <br /> License tt: 6-36sFs� Expiration Date: t/�1 7414by <br /> Dale: Contractor: <br /> Signature: Title: G4 ScKs c. � <br /> ! / V <br /> Prynletl name; <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 sslFinsure 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 workore'eompensatlon Insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit Is Issued. My worker$'compensatlon Insurance <br /> carrier and poi cy numbers are,. <br /> Carrier: �' Jer� i �/Lfyal Policy Number: LJG>� 7jo 7z334org <br /> 4❑e"that ill the perfasavarnca o(UW work(or vouch Rita perrttit is issued,I "nolemploy any person in <br /> any manner so se to beware sLI*ce la the workers'comperreal Ii of Callfomis, errd agree that if I <br /> should become subject to the workers'eom ansailon provisions or section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date:_ (Z I 3 Signature: <br /> Printed Name: Cayv� <br /> WARNING:FAILURE TO SECURE WORKeAS'COMPENSATION COVERAGE iS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIViL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($700,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FORIN SECTION 8708 OF THE LABOR CODE. <br /> _ �7 h C cam ^ I (C-57liconzad authorized representative),horoby <br /> authorize_ . /��.�;e/�4 �,' ...,.n., ✓'cclw�/1 K��� <br /> to Sign this San Joaquin County Well Permit Application 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 7,20001 MI <br />