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Jan 13 03 04149p Horizon Env. Inc 916 939 2172 P•2 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />.JOB ADDRESS: <br />P RMIT SR#:, OQ 3L� <br />l0$ <br />E, tkw.K�wr <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />1 hercby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Olvisiun <br />3 of the Bu6ine/s,S anld,Profession: Code and my license is in hitt force and effect. <br />License # lS� u� Expiration Data: 1 O --.2,1 C �' <br />Date <br />Signature: <br />Printed na <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations. (CHECK ONE) <br />_ I have and will maintain a certifioete of consent to solf-insure for worlters' compensation, as provided for <br />by Section 3700 of the Labor Code, for the performance of the wore forwhich this permit is issued. <br />have and will maintain workers' cerrnpencal on insurance, ac required by Section 3700 of We 'Labor Cadc, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and po'icy numbers are: <br />Carrier. �-C Policy Number: <br />1 ce•tify that in the performance o1 the work for whi ;h 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 />Sho,,ld become sub ect to the workers' compensatiyilprovisions of Section 7W of the Labor Code, I shall <br />forthwith comply with those orovistons, <br />Date:1 11 Signature: <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 HUNDRED THOUSAND DOLLARS <br />(5100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES. AN[) DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORI7ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />gnature ofC-37 IICQnse�o authorized repro$eWill ve), <br />hereby authorize (prfnYharne) r <br />to sign this San Joaquin County Well Permit APPlieation on my behalf, 1 unders nd this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front pgge of this application - <br />0 <br />ne n-) r ui <br />Z di30E0E I ESZ6 `JN I1 -II NG 993219 WdLE =b EOOZ 61 WUC <br />