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07/10/02 WED 13:10 FAX 650 691 9807 SECOR Z002 <br /> 16Uux <br /> "ban joaquin Gc>unty EnvironWen ta) Health Services, Unit IV Well Permit Application Rupp!®m£nt " <br /> JOB ADDRESS: ` r PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am hc:ensr:d under tl c provisions of Chaptsr 9 (cornmencing with Section 7000}r P Division <br /> 3 ❑T the Business and PrDfessions Code and my license is in full force and effect. <br /> License#: /r9O C4 Expiration Data: <br /> Date:. ontractor: 7 �C <br /> Sign ature., Title: �rJLJ <br /> Printed name: �Ac <br /> WORKERS' COMPENSATION DECLARATION <br /> I hdreby arrlrm unrJor penaity of perjury ono of the following declarations: (CHECK ALL THAT APPLY) 1 <br /> I have and will malntain a certificate of consent to self-Insure for workers' cdmpensatlon, as provided for by j <br /> Section 3700 of the Labor Code, for the performance of the work for which tni3 permit is issued. <br /> I have and will maintain workers' compensation Insurance, as required by Section 3700 of the Labor^ocfe, <br /> A for the pertormaneeh of the work for which th; permit is Issued. My workers' compensation insurance <br /> carrier and policy numbers are, <br /> Carrier: a _ -loll Policy Number: <br /> 1 certify that In the performance of the work for which this permit is issued, l shall not employ any person In <br /> any rnannfsr so as to become subject to the workers'componsvkicn Iowa of California, and agree that it 1 <br /> shvUld become sultOct to MG workers'compensation provisions of Seistion 3700 of the Labor Code, 1 shall <br /> forthwith campy with those provisions. <br /> Q <br /> y <br /> Date:_ Sibnature• }� � d <br /> IJ I / j <br /> Printed Name' �—i`�'�� <br /> WARNING=FAILURE TO SECURE wORKE"'COMPENSATION COVFRAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> +S4Do•000.),JN ADC)MON TO TME COST OF COMPENSATION, INTEFREST,ATTORNEY'S TEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> + �T lic�nscd T=LL 11—u <br /> � /' <br /> io sign thic San Jaacfuin Co4nty WCII Polit Applisatiot7 on my behalf. I ynderstand this authi26=tlon IA valid or 1 <br /> one(1)year and is i1mited to the work plan datad on thefro a of this a}i Itcation_ �. _J JI <br />