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10/06/1999 11:16 9167624P46 E"SPANA GEOTECHNICAL PAGE 02 <br /> 1 . 10-96-1999 .12:QSPM FRS P, 5 <br /> San Joaquin Cb'Untj 1EdVirchr1i6ntal Health 8elv{6es-,*Uni0V Wti 11'Pelttlit.Agplication Supptem'ent <br /> J013-ADDRESS: PERMIT <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 license is in full force and effect. <br /> License# 555 Expiration Date: I ZO© <br /> Date: ! Contractor. PG r--X PC—D 12-A1=1 O A,) LJUC- . <br /> Signature: Title: GCJV gs?fZl4t, rL Prig A-6 <br /> Printed name: 70Aie K1 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm-under penalty-of perjury one of the following deciarations: (CHECK ALL THAT APPLY) <br /> Z'I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Laboe.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. i � i �vlYll'�ti Policy Number. <br /> i <br /> X I certify that in the performance of the work for which this permit is iseued; I'Jk ail 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 /> i should become subject t6the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: o " Signature: <br /> Printed Name: <br /> 14QI <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL..,AND SHALL SUBJECT <br /> AN EMPLOYER TO.CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S106,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR 1N SECTION 3709^OF THE LABOR CODE. <br /> (C•57 licensed authorized representative),hereby <br /> authorize <br /> to sign this San Jodquln County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and Js Ifmlted to the work plan dated on the front PaRe of this 8 plication <br /> ZOO12j N011vH071dya 0d 90ZV tct 9T6 Yvd. LT:ET 66/90/OT <br />