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01/18/2003 SAT 09:94 FAX2 002/002 <br /> s � <br /> San Joaquin Co E vironrnental Health Servicee,Unit IV t ell PermitrApplioation SURAtBment <br /> JOB ADDRESS: <br /> ` + PERMIT SR#e_ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 8 (Commencing with Section 7000)of Divisron <br /> 3 of the Businre�srsl and Professions Code and my license is in full force and effect. / <br /> License : I c� ry Expiration Date.�Z�/n'^` <br /> Ip ontractor. f <br /> Date:_ �J /1 <br /> I J Title: <br /> Signature: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I 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 /> v1 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; 1 L� I Policy Number: <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 become subject ' the wlaws 371DO of the LaborrCode, I(shall <br /> should become subject to the workers' compensation provisions of Section, <br /> forthw!T comply with those provisions. <br /> Date: 1 Signature:_-.. <br /> Printed Name: �_� Yi I <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 /> ($ROV DED FNECTION 37 6 OF NA SCOST <br /> OF COMPABORENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> (C-57 lieens a therized representative heredy <br /> authorize V C• ' <br /> to sign this San Joaquin County Well Perm Applicat on my behalf. I understand this authorization valid for <br /> one(11 year and is limited to the work plan dated on tho front age of this application. - <br /> W(;2j� WdPS L'I L 66F?I--VCS—C3I <br />