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AUG 2202003 11 : 43AM Hf' LASERJET 3200 p. 2 <br /> 08722/2003 11:38 2095224 `� CULWIuAL itrvi� ^�� <br /> C�oO/ & -� <br /> Sen Joaquin Gpu vironftlohYat t'lealttl reta►,cee,fJ,iit N 1Nrli1!'f5efxnit J►g frlfoRtloR Supplement <br /> JOB ADDREM <br /> LICENSED CONTRACTORS DECLARATION ( 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 <br /> tt and Professions rCode and my license Is in full force and effect. <br /> License Expiration Date: CC <br /> Date; Contractor: '�T it 1 ��L IQ <br /> Signature: Title' <br /> Printed name: /� 4 <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 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 wortcers'compensation,as provided for by <br /> ton 3700 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 for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier. 0 Policy Number: <br /> rlify 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 Code, 1 shall <br /> forthwith/comply with those provisions, <br /> Date: 1 35 • Signature, <br /> PrinteS Name, Q <br /> WARM NIG:FAILURE TO SECURE WORKER6'COMPENSATION COVERAGE Is UNLAWFUL.AND SHALL SUBJECT <br /> AN L'lllp'LOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (Stoo,000.),IN ADDITION 70 THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS i <br /> PROVIDED FOR IN SECTION 37066 OFTHELASOR CODE. <br /> (C-57 licensed authorized representative),hereby <br /> aucherl:. <br /> G YCA kr <br /> to*hM this Sari Joaquin County Well Permit App cation on my behalf. I understand this authorization is valid for <br /> on!.Q)year and is limited to the work elan dated an the front page of this Application. <br /> £.d WO?� WdL.E z E 6661-5Z-0 I <br />