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FROM West Hazmat • FAX N0. 19166388613 • Sep. 18 2001 09:58AM P2 <br /> R <br /> lion Aoaquin_[:oulltyEnvirogm�ntal Health Sorvlces, Unit IV Well Permit AppllcatiorrSupploment <br /> id.13A1T]•UFt��$,= ���� . �`'.4cl��C A+� PERMIT SR#:QD� S. <br /> LICENSED CONTRACTORS DECLARATION L( CDl <br /> 1 hereby affirm that I am licensed under the provisionp of Chapter 9(rornmoncing with Section'1000)of Division <br /> 3 of the Business and Professions Code and my license is in full forte and effect. <br /> License#: s y 5.7 5 Expiration Date: <br /> Date: . OF- 18-01 Contractor: , l!✓ �z. n�' �lvc.c. rt �o,a�" <br /> SI®nat�raL •._. _TIt10:_ G�6/ON YC- `✓��n1iYp(s11 <br /> Printed naov6 cert drl e./1.f7�l <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby atfirm 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 workors'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 ave and will maintain workers'compensation Insurance,as required by Section 3700 of the Labor Code. <br /> for the performance of tho work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier:_-1— ✓H�`7 �k° `Policy Number: �-A,W (3✓6/'27`1 <br /> I certify that In the performance of tho work for which this pormit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California. and agree thnt if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: U g'/� � ... Signature , l ",U). <br /> Printed Nam 1 �' cr1s� jr <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 SECTION 3706 OF THE LABOR CODE. <br /> C-57licensedauthorized reprassntative),hereby <br /> aetha - Y�f� ts-G�7�-�}!1^ rJ.t�` ��iU,✓�/td N F-iL- Y'-/Yl�' �u 10.. i <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 Oils application. <br /> 5.17.20001 MI <br /> 00 3Ovd WO-1-1 R"I8 EEbESSp60Z vs:Lo 000Z/9Z/9'C <br />