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- San Joaquin County Environmental Health Semites, Unit IV Wilt Permit Application Supplemarg <br />JOB ADDRESS: ! 1 Rmrr S <br />I hereby of rm that I am Jicansad under the provisions of Chapter a (cornmenrang witt Section 7000) of Division <br />a of he Business and Professions Code and my license is In full force and affect <br />License #: <br />Date; ' )1 w f ul Contractor, <br />Signature: <br />Printed name: <br />Expiration Date: <br />WORKERS' COMPENSAii0N DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />—Iha and will maintain a certificate of consent to self insure for workers' compensation, as provided for by <br />��Sectlon 3700 of the labor Code, for the performance of the work for which this permit Is issued. <br />V 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 policy numbers sr6: <br />Carrier: shoe ParkAr Policy Number: d'(p <br />y I certify that in the performance of the work for which this pem►it is issued, I shall not employ any person in' <br />any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if i <br />should become subjsd to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: L Signature: <br />Printed Name: <br />WARNING: rAILURE TO SECURE WORKERS' COMPENSATION OVERAGE 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 Or- COMPENSATION. INTEREST, ATTORNEY'S FE11-1-5, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br />C4 12,E (Cy7 licensed authorized repnurentat V), hereby <br />4'd (J)1-00cltll ill ill" <br />to sign this Sun Joaquin County Well Permit Applicatlon an my behalf. I understand this authorization Is Valid for <br />one (1) year and is limited to the work plan. dated on the front pagor of this applfcMon_ <br />5-17-2000 I Ml <br />