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FROM West Hazmat • FAX NO. 191163e8613 • Sep. 18 2001 09:59AM P2 <br /> !inn Joa uin.4otElviro m ntal Health Sorvlces Unit IV Well PermitA P' Ilcatlon'SuPP1pment <br /> J60' A6PR <br /> 115,''S r AfW,�?.0 A ,. PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provision 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#:_3.s Y 5 7 S Expiration Dale; <br /> Date: o 7- !B o l _ Contractor: <br /> SlgnatLnr _ C • ,-, �1 _71t10' G' 6/bN�YL �i�J,r �•rav✓t <br /> Printed naotAf ur ^ A drLe! c�tAr-! <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratlons: (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 /> ZI have and will maintain workers'componsation 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. (- 4/` 1 6P ° Policy Number: ZL W V 6e? Z7 <br /> _I certify that In the performance of tho work for which this permit is issued, I shall not employ any person in <br /> any mannor so as to become subject to the workers'compensation laws of California, and agree that if <br /> should become subject to the workers'compensation provisions of Soction 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: D 5-/9•6 l Signaturale'- <br /> PrintedName-- <br /> Z!"4-rr'-:a -_.-- <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 /> PRUVIDED FOR IN SECTION 3706 OF TI4E LABOR CODE. <br /> -- <br /> _(C-51 licensed authorhed representative),hereby <br /> autho7 f� tG/rV}f1^ tJMr Env✓ /LG FJHCTrT11 L' ✓ O� <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorisation Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> 5-17.20001 M I <br /> 00 39vd I-11dii EEDEB9dG0L 6S:C0 0002/SZ/0i <br />