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04/08/2002 MON 14:06 FAX 001 <br /> ORIGINAL. <br /> San Joaquln County Environmental Heaith Services,Unit.-IV Well Permit AppSication Supplement <br /> JOB ADDRESS: PERMIT <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 0 (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#: /�a a`� Expiration Date: <br /> Date' <br /> Q contractor. <br /> Signature: (( c Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <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 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> V//I have and will maintain workers'compensation insurance, as required by Section 3700 or the Labor Code, <br /> r`for the performance of the work for which this permit is issued. My workers' compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier: C L. _Policy Numbac <br /> i certify that in the performance of the work for which this permit is issued, i shall not empiOy 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 co ply with those provisions. <br /> Date: Signature: <br /> Printed Name: <br /> WARNING. FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PF-NALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100.000), IN ADDITION TO THE COST OF COMPENSA-nON, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 7 <br /> 1 (0-57 licensed a orizepresentative), hereby <br /> authorize <br /> to sign this Sian Joaquin County Well Permit Applicat on on my behalf. I under-stand thi9 authorization is valid fos <br /> one(1)year and is limited to the work plan dated on the front page of this application- <br /> 'ci I'IUcJ� iJdpS-0 L i- VO-171 L <br />