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a � <br /> I <br /> San Joaquin County Environmental Health Services, Unit IV Well ermit Application Supplement <br /> #JOB ADDRESS: %SGS S. A�ER IIT SR#: Del ZG <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (comm ncing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and ffect. <br /> License Expiration Date: (( 3() (O I <br /> Date: Contractor: ���� `dp <br /> ppp I <br /> Signature: 1 Title: <br /> Printed name: lU t r <br /> WORKERS',COMPENSATION DECLARATION <br /> i <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 whiIch this permit is issued. <br /> have and will maintain workers'compensation insurance, as required thy Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My worl�ers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier:� �, F� Policy Number: 1, TA 11 —O a <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 to become subject to the workers'compensation lawsi of California;and agree that if I <br /> should become subject to the workers'compensation provisions of Sect(on 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. (/�/ <br /> Date: . I ��(o( 61 Signature: \ 'n A <br /> Printed Name: .- . �, <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 HUND ED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATT NEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, (C-57 licensed authorized representative),hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 5-17-2000/Mi <br /> —war�15615 IIS 'SEVENTH 'IST <br /> Address ma <br /> city GbdB ... __. I <br />