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11-22-1999 FROM P_ 0 <br /> a <br /> J <br /> i <br /> San Joaquin County Environmental Health Services,Unit-iV Well Permit Application Supplamant <br /> jOB ADDRESS: d<-hQVW1�14d, -ff6 PERMIT SP?#: 0 f 2 f <br /> LICENSED CONTRACTORS DE(1`>L ARATi0N' -!' CC,) <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 Expiration Date: <br /> Date: Contractor: ' T�'(/`V'�j �v) CX A ln✓'c TID V, \ <br /> Signature: Title; <br /> h ,nfr�lr <br /> Printed name: <br /> c <br /> I <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHEC'K ALL THAT APP-L-"!) <br /> I have and will maintain a certificate or consent to self-insure for workers' compensatio^, .as rrrn;idad 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 tha L abcr Code, <br /> for the performance of the worts for which this permit is issued. My workers'compensa-:ion insurance <br /> carrier and policy numbers are: <br /> Carrier: Policy Mumber. <br /> I cer-tiry that in the performarv:e of tha work for which this permit is issued, 1 shall not employ zamv person in <br /> any manner so as to become subject to the wWo ers' compensation laws of Califomia, 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 comply with those provisions. <br /> Date: 1/6Signature; ; <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION ERAGE IS U?3:AAWFUL,A? SNAIL 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,ATTORNi`'tCS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> I, (C-57, licensed authorized r6presentativs), hersbv <br /> authorize ,Se't Q i�IAv�C/ �� ,? V- <br /> to sign this San Joaquin County well Permit Application on my behalf. I understand this autho iracr.s, vl:d for <br /> one(hoar and is limited to the work plan dated on the front page-orf this application. <br />