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E12/25/2003 16:40 2094683433 FIFTH FLOOR PAGE 05 <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 19SSS N, T„IY R1, LDcke-F n' PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions 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#: 4 0 6 5(:,6 Expiration Date: X31 �c:J <br /> Date, 3/11413 contractor: r i; /yoc27�"/z#t�l e-tAL ror2.ryt4 MAC- <br /> Title:_ Title: fl(2 f L'z-d r� <br /> Si nature: / <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 /> 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 /> __�'Jhave 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: <br /> FuNp 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 to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith com ly with those provisions. <br /> Date: 3 (( O Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 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 /> 1, (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf_ 1 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 1 MI <br />