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Mi 12 2003 10: 23AM 6LASERJET 3200 • p. 2 <br /> 03/12/2003 09:46 CLR 14 3130302 N0.625 P05 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> J 0 8 ADDRESS: ANS5-4VeD AAArli° n ' PERMIT 5R#:&�3 ' <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 effedl. <br /> License iii .,����r Expiration Data, <br /> r <br /> Date: ! O contractor: <br /> Signature: Tills: ar6Of1 r//�JUy��O�A�r <br /> Printed Hama,� �� ii <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. <br /> X,t have and will maintain workers'compensatlon 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 g s_ Pollcy Number. !a:&Q 97a C <br /> 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 N 1 <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: j' Z/OSS 51BnIII re: <br /> Printed Name, <br /> oli <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 5706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR,QTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 11 (signature oIC-57 licensed authorized rapresentative), <br /> hereby authorize Iprint name) <br /> to sign this San Joaquin County Wall Permit Application on my behalf. I understand thie authorization la valid for <br /> one(1)year and Is limited to the work plan dated on the Mont page of tale application. <br /> 8-90-021 MI <br />