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01/17/2003 FRI 15:51 FAX IM 002 <br /> 1> <br /> r" <br /> h t <br /> San Joagrlln Co E vironmental'Health Servlol,Unit"IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#> <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 8 (commencing wial Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force land effect. - <br /> License*: l�D7C�7 //e _Exlpiirrmion Date: <br /> Data: , LQ <br /> _ ontractor:,L13 a to?11f �Signature:Pnnted name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of tho 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 <br /> .,,,►policy <br /> �numbers are: <br /> Carrier: '" 111G1L Fu ric1 Policy Number, i�� 4- <br /> 1 <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of California,and agree that if 1 <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwi Tco ply with those provisions, <br /> Date: ' Signature:__41 �• U '�yL , <br /> Printed Name:�w,�.�-u <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANP CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE CAST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> t, (C-57 lieens a homed repmsentagve hereby <br /> authoriza I �1 ft <br /> to sign this San Joaquin Ceunty Well Perm Appltca on my behalf. 1 understand this authorizatiol-6 valid for <br /> one(1)year and is limited to tho work plan dated On the frent page of thiE applfCatlon. <br /> woad wvrs>ot FCn6I-70-01 <br />