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SanJoaqu►n:C-otlnty Environments' �Ith Services; Unit IVWelt Perm itApplica_t <br /> supplement—PERMIT <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 1 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#:_Bl i�Y Expiration Date: b i--31 W1 <br /> Date: 06 • /! '6 ' Con tractor:�S+ n C'1 2)X4(-4-," C PC <br /> "Si <br /> Signature- V - Title: <br /> Printed nam : C'��''a /� °j'xGtit►�� <br /> WORKERS' COMPENSATION DECLARATION <br /> 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 /> Carrier: 44-T1=616.4 /-5• Policy Number: 2 Z W dVKirt 7/3 ( <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of Cafifomia, and agree that if <br /> should become subject to the workers'compensation provisions of Section 3700 of the La de, I shall <br /> forthwith Comply with those provisions. <br /> Date: O 6- ♦ -e 6 Signature: <br /> Printed Name 4- <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 THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTIONS 37706 OF THE LABOR CODE. <br /> r, l Cefits4 4, _ <br /> (C-57 licensed authorized representative),hereby <br /> authorize m Ile t I-I J2 Z) <br /> to sign this San Joaquin County Well Permit Application on 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 /> 5-17-2000 1 MI <br /> VO 39bd a00-1d HldId EEbE897606 vs:Lo 0002/96101 <br />