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04/04/2002 THU 09:04 FAX 002 <br /> FILE "'ripl <br /> San Joaquin County Environmental Health S.etvices,Unit IV Welt'Permit Application Su/p}Cte/ment <br /> JOB ApDRESS: 2�� �'n�' PERMIT SRR'. �! 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#: /�Q' p"7 _Expiration Date: d���� <br /> Date: -1 �/ ontractor: <br /> Signature: (( //�� _ Title: <br /> Printed name: �.InCLJL(.S '�" <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 /> ✓/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: Policy Number: 7-5.3 <br /> ��cert�ty that in the performance of the work for which this permit is issued, 1 shall nflt employ any person In <br /> ak,y manner so as to become subject to the workers'compensation laws of California,and agree that if J <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- y Signature' <br /> Printed Name: _ y'", <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 TNF_COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,ARID DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> i (C-W litensed a 40rize r prescntstive), hereby <br /> authorize ,;a <br /> to sign this San Joaquin County Well Permit Application oh my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to,t c work plan dated on the front page of this Application- _ <br />