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10/16/2002 WED 14:50 FAX 0002 <br /> San Joagttln County Environmental Health SorvlceR.Unit'IV Well Permit Application)Stipple ant <br /> JOB ADDRESS: _ PERMIT SRM: 5( U <br /> JZ,,j-) y C/'� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am lirensed under the provisions of Chapter 8 (commencing with Section 7000)of Division <br /> 3 of the Busin�e/s�st and Pr <br /> o <br /> fessions Code and my license is in full force land effect. <br /> License#: /cx� U7 Expiration Date: l"\ <br /> onlractor. �l l nn li ei <br /> ` /n{- Title: CYC'- 7 <br /> Signature: j + / <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARAVON <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 self-insure for workers' compensation, as provided for by <br /> Section $700 of the Labor Code, for the performance of the work for Which this permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work far which this permit is issued My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: I �FI.lY'1(l Policy Number; <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 if I <br /> Should become subject to the workers' compensation provisions of Section 3700 of the Labor Lode, I shalt <br /> forthwith <br /> amply with <br /> jthose <br /> ' provisions. <br /> Date: )t i t l'--1 1 U 5lgnature: ... l.u,L •_. L�1J7ye.� - <br /> -+�-" Printed Name: 0 T, <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TD CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED FOR ADDITION <br /> IN SECTION HE OOF TH F OMP NSATCODE!ON.INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> 7 <br /> 1 � -571ieenced autkerired rOPreqn121,1V hereby <br /> her a <br /> to sign this Sen Jo¢q in CountyWell Prmit pPlication On my behalf. 1 undoistand this sd,hoalid[m <br /> one(1)year and is limited to the work plan dated on the frontage of this application. <br /> WOd_1 "MI/13401 Ei66 L-ro. Lit <br />