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OCT 31 2002 11 : 02AM HP LASERJET 3200 p. 3 <br /> OCT-30-2002 16:59 ?S CORPORATION 415 243 3898 P.03iO3 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: DERMIT SR#: d 3� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 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#: C—S 7 WtC r Expiration Date: _1 iIil3t <br /> Date; O 3 Contractor; ._rc-F W ,r�l i►� <br /> Signature: Title:C09096on,t&a?gyeoa,- <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratio^s, (CHECK ONE) <br /> -19'I have and will maintain a certificate of consent:to self insure for workers' compensation,as provided for <br /> � <br /> /by Section 3700 of the Labor Code, for the performance of the work for which This permit Is Issued. <br /> Y01, <br /> 1 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'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: 40 �� Policy Number eg 3 <br /> I certify that in the performance of the work for which this permit is issued, I shall not emp'oy 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, I shall <br /> forthwith comply with those provisions. <br /> Date: /0 61&7, Signature: CI�/ll+ti't_ <br /> Printed Name: P/-4ef i <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 /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST, ATTORNEY'S FEES,AND DAMAGES A8 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> �LAUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> �(signature efC•57 licensed authorized representative), <br /> hereby authorize (print name) <br /> to sign this San Joaquin Counly 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 /> 6-29-02/MI <br /> TOTAL P.03 <br />