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07/31/2002 08- 47 2694683433 FIFTH FLOOR PAGE e4 <br /> C�1i11/2�702 16: 59 20945834:3 FIFTH FLOOR PAGE 05 <br /> San Joaquin County Environmental Health Services, Unit FV Well Permit Application Supplement <br /> .IDB ADDRESS: 16111 Wesk- Pco-tMon4- Ave- PERMIT SR#; 3 0 <br /> Sko c14OVI,C-A <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <br /> i hereby affirm that I am licensed under the provisions of Chapter 9 (oommoncing with Section 7000)of olyision <br /> 3 of the Business and Prnfeassions Code and my license Is in full force and effect. <br /> License#: o:(pJ�SJ �O Expiration Diate3: D ` 3 r 0 3 <br /> Date. 7 — 41 , Contractor' PCC t-a h -r/IG <br /> Signature: Title. Jf <br /> Printed name: 015 Fter) <br /> WORKERS' COMPENSATION DECLARATIDN <br /> I her"y affirm under penalty of perjury one of the following declarations: (CHECK A-L 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 /> X1 have and will maintain workers'compensation insurance~,as required by Section 3700 of the Labor Code, <br /> • for the performancg of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy n-u7-mb�errs, are: / Q <br /> Carrier: I! -� �s�r C.1�GriY)C� Policy Number: (21 � 7 C�q <br /> 1 certify that in the performance of the work far 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, 1 shall <br /> forthwith comply with those provislohs, <br /> Date: . Signature: <br /> Printed Name: <br /> WARNING: FAILURE To SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRWINAL PENALTIES AND CIVIL FINES UP TO ONE MUNDRE13 THOUSAND DOLLARS <br /> (S1OaA011.),IN AUDITION!TO THE COSY OF COMPENSATION.INTPREST,ATTORNEY'S FEES, AND 47AMAGES AS <br /> PROVIDED FOR IN SIE"ON 3705 OF THE LABOR CODA_. <br /> I, gnT 4 __ _ (signs+are ofC-57 IitsRsad :30h Prized represontati►ve), <br /> horeby authorize[print name) r-1 e l- l4 4 j <br /> to sign this San Joatpuin County Wall Permit ApplieaRlon on my behalf. I undefstand this authorization is valid for <br /> one(1) year and is limited xo the work plan dated on the front page of this applicat)on_ <br /> 5-17-21100 J MI <br /> • <br />