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SEP 30 2002 4: 02PM H— LASERJET 3200 J p. 2 <br /> Sep 30 02 02: 48p Ho�Yon Env. In$ 916 92172 p. 3 <br /> Cis27-4? <br /> San Joaquin County Environmental Health Depat IV Well Permit pplicatlon Supplement <br /> JOB ADDRESS: 34,go tf 5� PERMIT SR*:,d2�3� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (Commencing with Section 7000)or Division <br /> 3 of the Business <br /> _and Professions Code and my license is in full force and effect. <br /> rd+ <br /> License At:_�bto 1Expiration Date. _r,l�7 t L 2- <br /> Date, - Contractor: <br /> Signature: Title: 6 <br /> Printed nafne: r ��e-IL— <br /> WO KERS' COMPENSATION DECLARATION <br /> I hereby affirm 1,10def penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate Of consent to self-insure for workers'compensation,as provided fur <br /> by Section 3700 or the Labor Code,for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensat'on insurance as required by Section 37p0 of the Labor Code, <br /> for the performance of time wurk for which this permit is issued, My workers'compensation insurance <br /> carrier and policy numbers are* 2 2 <br /> Carrier: Policy Number. J ✓_ r�� _ <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any parson in <br /> any manner so as to b000me subject to(lie workers•c ensation laws of California,and agree that if I <br /> should become subject to the workers'Oompe a n provi ons of Section 370 of the Labor Code, I 'shalt <br /> forthwith comply with those provisions, <br /> Date: O Signature: r� <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVfL FINIS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($103,000,),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I' (signature ofC.57 licensod authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Woll Permit Application Ott my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-OZ/MI <br />