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04/08/2002 MON 14:06 FAX 2001 <br /> -NOW, <br /> San Joaquin County Environmontai Health Services,UnIVIV Weft Permit Application Supplement <br /> JOB ADDRESS: PERMI Std#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I 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 : 1 aD oA Exp <br /> ira <br /> tion Date: <br /> Date. I H O r�&dbi /-)` <br /> contractor: \14 <br /> Signature' + / cTitle: <br /> Printed name: dJ��V� -• <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 /> 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 /> Carcier: C rale Ll Policy Number: d1 <br /> certify that in the performance of the work for which this permit is issued, i shall slot employ an person in <br /> any manner so as to become subject to the workers' compensation laws of California, and agra3 that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code. t shall <br /> forthwith co ply with those provisions. <br /> Date, D signature: <br /> Printed Name: WltrL� <br /> WARNING:FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> JN ADDITION TO THE CAST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES A$ <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, (C-57 licenseda Drize presentatlVCj, Hereby <br /> auth �--F� <br /> to sign this San Joaquin County Well Permit Applioat on on my taehalf. I understand this authorization 1s valid for <br /> one(1)year and is limited to the Work plan dated on the front page of this application. <br /> F 'ri I'IUd� 1Jd7�'C1 t fiE,F,l 170-0 t <br />