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Nov- 18-99 04 : 50P VIRONF" , INC _ 510261r�0963 P _ 02 <br /> nuv.16. i y�y 11:ZieWl _ . .�1'G� h Ei963 110.700 P.2 <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:__3�0 M. 66, so, SY. PERMIT SRO: <br /> I <br /> LICENSED CONTRACTORS DECLARATION (L,CQ) <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 <br /> Code and my license is in full force and effect. <br /> License# CS 1 7�S7 Expiration Date: <br /> Date: _ 1/f/Tf` Contractor: yi 4l)w e x Triy- <br /> Signature, <br /> 9 Title: -lac, <br /> Printed name: ,. A S S t- <br /> WORKERS' COMPENSATiON I)ECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations. (CHECK ALL THAT APPLY) <br /> I have and wilt 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 /> ✓ 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 /> a► <br /> Carrier: Uv:;fe4 1',q[; }' I-vtf a• Policy Number: NV114 %t S_ / dC0 1 q 1 <br /> I certify that in the performance of the worts 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 Code, I shall <br /> forthwith comply with those provisions. <br /> Date: /��t�S S Signature: <br /> Printed Name: 7e K I�'lc 495 1_:4 <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 AS I <br /> PROVIDED FORMAN SECTION 3706 OF THE LABOR CODE. <br /> (C-67 licensed authorised npessantatlwX he.vby <br /> authorize_ rza.,`t ALK-eh- (rA,.dwca -1- !moi6) <br /> to sign this San Joaquin County Well Permit Appil ation on my behalf. I understand this authorization is valid for <br /> ane(1)year artd Is limited to the work plan dated on the front page of this application <br /> V d t�02�d Wd55 D 6861-L i-i l <br />