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JUL-02-2002 14:26 FROM:PRECISION SAMPLING 5102374575 T0:650 691 9837 P.3/3 <br /> 96/19/2882 14:Yy 1094b' 1-1 r it i n rt-un-^ --� -- <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: �fnC ���nam ��i�1l� �! ���/ � � PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION CD <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 and Professions Code and my licensc is4n full forte and effect, <br /> License : 6-�$ Expiration Date: <br /> Date: Contractor: <br /> Signature. Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty or 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 warkers'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 /> terrier anr"ro' numbers�nerre: r <br /> Carrier_ Z- "4 fi"+ I PolicyNumber: LOC't ,q'7/ 0-7133"? 01' <br /> I certify that In the performance of the work for which this permit Is'lasued, 1 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'cornpensation provisions of Section 5700 of the Labor Code. I ariall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed Naha; <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN E34PLOVER TO CRIMINAL PENALTIES AND CML FINES UP To ONE HUNDRED THOUSUWD DOLLARS <br /> ($100.000.1.W ADDrMN TO THE COST OF COMPENSATION,INTEREST,ATTORNEYS FEES.AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 9706 OF THE LABOR CODE <br /> 1, (sigAature ofC 57 licensed aunwrtted reptesentatlaek <br /> he uthorize(print ngrRe) �'�✓t "'o"t'Q`�`� ^ Ca <br /> to sign this San Joaquin County Well Permit Applleation on my behalf. 1 understand this autheft-W an is valid for <br /> one(1)year and le lied od to the work plan dated an the front page of this applleslforL <br /> s���000 t kl1 <br />